812 Innoventions Innoventions Innovators making inventions

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812 InnoventionsInnoventions Innovators
making inventions

• Divya Shroff, MD Cairo Handoff
• James Edwards, MD Portland Surgery Case Manager
  
• Jasbir Mavi, MD SupraVista

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Things to Remember

• Questions will be answered at the end of the 3
  speakers talks
• 3 x 5 cards are available around the room
• Please jot down questions for the end
• All talks will be available on the Web after the
  lecture is over

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CAIRO Shift-Change Handoff Tool for Physicians

• Divya Shroff, MD, Senior Hospitalist
• Washington DC VAMC
• Richard J. Sowinski, Chief of Application
  Development, Roudebush VAMC, MSCS, BSEE
• Charlet Lynn Cottee, Senior Developer,
• Roudebush VAMC, BSCS

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Why is Handoff important?

• Reduce likelihood of medical errors and
  misinformation
• Prevent lost or missing clinical information
• Maintain a high level of medical care
• Increase efficiency/flow
• Decrease cost of multiple tests/length of stay
• Key issue for across all levels of medicine -
  MDs/RNs/Clerks
• Nursing shortage therefore, temporary staff
• House staff shift guidelines
• Larger surgical teams due to advanced technology

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Barriers that lead to need for Standardized
Handoff

• In todays climate of short hospital stays and
  complex patients, need for timely and effective
  communication
• Work hour limits for residents lead to increased
  number of patient handoffs and potential for
  communication breakdown
• Decrease in continuity of care/miscommunication/in
  crease in cross-coverage
• Missing information in a non-standardized system
• High variability
• ex) Code status/allergies missing in 80 of
  recent studies

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What does a handoff need to address?

• Standardized
• Written and Oral patient summaries
• Communicate in effective and efficient manner
  during sign-out
• Demonstrate read-back skills when communicating
• Evaluate all up to date medications
• Anticipating what may go wrong with patient after
  a transition in care occurs

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Key points to remember

• The physical setting confidential/ quiet/
  minimal distractions
• The social setting comfortable along all levels
  of hierarchy
• Language barriers avoid colloquialisms/ only
  accepted abbreviations
• Medium of communication face to face vs.
  phone vs. email / written vs. oral
• Time / convenience issues standardized system
  will increase efficiency
• Education issues formal curriculum to
  demonstrate effective handoffs
• Ref Lost in Translation Challenges and
  Opportunities in Physician-to-Physician
  Communication During Patient Handoffs, Academic
  Medicine, Dec 2005

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What should be in a successful handoff?

• Team Identifiers - Staff names, phone numbers,
  covering staff contact info, distinctive team
  name/color
• Appropriate patient identifier - 2 forms of
  identification
• 1-2 sentence of patient presentation
• Active problem list - pertinent past medical
  history
• Medications all active listed
• Allergies
• Access - Venous / Arterial Access and what to do
  if changes
• Code status
• Pertinent labs
• Concerns over next 18-24 hours and what to do in
  those situations (problem vs. system based)
• Long term plans / family questions that could
  arise if indicated
• Psychological concerns
• Ref Lost in Translation Challenges and
  Opportunities in Physician-to-Physician
  Communication During Patient Handoffs, Academic
  Medicine, Dec 2005

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Everyones talking about handoffs

• VHA National Findings and Recommendation For
  Improving Patient Handoffs
• 2007 National Patient Safety Goals
• 2007 Joint Commission Frequently Cited Standards
• VHA FIX/Flow Effort
• SBAR - Situation/ Background/ Assessment/
  Recommendation

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CAIROs History

• Created by Indianapolis (Roudebush) VAMC with
  inputs from pilot testers at the following VAMCs
  Washington, DC Iowa City Des Moines Ann Arbor
  Loma Linda Dallas White River Junction
• December 2005
• Paper published in Academic Medicine by
  Indianapolis VAMC Lost in Translation
  Challenges and Opportunities in
  Physician-to-Physician Communication During
  Patient Handoffs, Academic Medicine, Dec 2005
• January 2006
• New JCAHO Patient Safety Goal to standardize
  Handoffs goes into effect, and NCPS issues
  summary advice to VAMCs on topic.
• July 2007
• CAIRO Tool installed being tested and/or used
  at 12 facilities.
• Several other VAMCs expressing interest.
• Communications with New Service Request submitted
  by NCPS to VHA OI to plan to upgrade software
  from Class 3 to Class 1.

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CAIRO Hand-off ToolUser Guide Version 5.5
CAIRO Hand-off is a form of communication tool
for transferring care of patients among
physicians for example when one physician leaves
at the end of the day and hands off his patients
to a physician on call.
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At any point, you can start over with your
selection by pressing this key
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Click on the provider name that is desired for
the sign-out (i.e. will show up on right sided
column)
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H.O.T. Hand-Off Team List CAIRO specific list
where various team names can be created based on
site requirements
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Identical format to CPRS in retrieving patients
name
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Double click on patients name to add to right
side
Three choices on saving the new patient addition
to the current sign-out list
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This list will save in both CAIRO and CPRS
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For the administrators To create HOT lists and
identify users To create team headers with
names/titles/numbers Designate field preferences
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To specify who can access / modify specific HOT
teams
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Pros for CAIRO

• Uniformity
• Built within VA
• Works with CPRS
• Med reconciliation
• Legible
• Forces updates
• Site/service tailored
• Time saving
• Paperless in future

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• For further information about CAIRO,
• please contact
• Noel Eldridge noel.eldridge_at_va.gov
• Rich Sowinski richard.sowinski_at_va.gov

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References

• Wall Street Journal, Tuesday, Nov 14, 2006 A
  Hospital Races to Learn Lessons of a Ferrari Pit
  Stop
• Academic Medicine, Vol. 80, No.12/Dec 2005, Lost
  in Translation Challenges and Opportunities in
  Physician-to-Physician, Sollet, DJ Norvell, JM
  Rutan, GH Frankel, RM
• The Hospitalist, March 2007 Hospitalists and
  Handoffs

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VeHU Class 812 InnoventionsSURGERY CASE MANAGER

• PRESENTED BY THE
• PORTLAND VA MEDICAL CENTER
• OPERATIVE CARE DIVISION
• James Edwards MD
• John I Thomas, programmer (retired)
• Evelyn M Braibish, RN (retired)

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Surgery Case Manager

• Rationale VISTA surgery package is not user
  friendly, not graphical, often requires double
  entry of data
• Goals
• Minimize data entry once only
• Allow audit of time from entry to operation
• Allow tracking of issues that need to be resolved
  prior to operation
• Graphical surgery scheduling

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Surgery Case Manager

• Not a complete surgery scheduling package
• Not meant to supplant VISTA surgery package
  rewrite
• Could be modified for clinics and other procedure
  areas
• Still beta, and class 3

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Surgery Case Manager

• Talk will cover
• Data entry into CPRS
• Surgery Case Manager
• Various lists
• Scheduling
• Administration

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CPRS Request for Surgery Note
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CPRS Request for Surgery Note
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CPRS Request for Surgery Note
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CPRS Request for Surgery Note
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CPRS Request for Surgery Note
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CPRS Request for Surgery Note
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Surgery Case Manager
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The Surgery Case Manager (SCM) is specialty based
using parsed data stored in a signed TIU Request
for Surgery progress note. Once that note is
acted on in the SCM it stores data in the surgery
file. While management of surgery data is the
focus at this time the SCM format could be
utilized by other services that need to schedule
and track procedures.
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Surgery Case Manager
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Direct Entry
It is possible to utilize a direct entry option
to place a patient on any of the lists (action
required, wait, and requested). These options
require that all required elements be hand
entered before an entry is successfully made. Use
of the Request for Surgery progress note, rather
than a direct entry, parses out most of the
required data elements. This allows for a
quicker entry with no repetitive data entry.
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Currently scheduled cases A scheduled case is one
that has been put on the surgery schedule but the
procedure has not been completed. The user has
been able to move data from one list to another
without repetitive data entry. Movement from one
list to another is maintained and viewable from
the audit trail.
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Surgery Case Manager
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Surgery Case Manager
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Surgery Case Manager
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Tool bar functions Settings for each surgical
specialty are identified here. Each site is able
to individualize basic data regarding the
specialty utilizing two categories basic and
surgeons.
When a name is entered the position can be
identified.
Providers position can be edited and the name
can be inactivated.
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Site Parameters found undertools in the tool bar.
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Audit Trail Displays all entries or changes to
the record with date, action taken and name of
individual who made the changes of movement.
This information is retained at all times, even
after the procedure has been completed.
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SURGERY CASE MANAGER

• TECHNICAL INFORMATION
• V2.6

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• The SCM uses the VA Broker to communicate with
  the Vista database. Log-in is done using the
  standard Vista access and verify codes. At the
  present time the application is made up of the
  following pieces
• Mumps routines (APT namespace) 10
• RPC calls 111
• Vista files (648 number series) 8
• SCM executable (Delphi) 1.53mb

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• The SCM makes no modifications to national
  Surgery package routines.
• A new cross-reference is added to the Requested
  field in the Surgery file (130) in Vista.
• There are two optional cross-references added to
  the New Person file (200) in Vista that are used
  to limit the number of users displayed when
  selecting User names and Provider names.

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Summary

• Surgery Case Manager allows tracking of surgery
  cases that need to be scheduled and that are
  scheduled
• Auditable
• Double entry is eliminated
• Graphical scheduling of surgery cases
• Extendable to other clinics or procedural areas

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VeHU Class 812 InnoventionsSupraVistA

• Jasbir Mavi, MD
• Salem VAMC

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Managing Clinical Errors, Patient Safety
and Provider Efficiency withAutomated Clinical
Decision Support
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Today, more and more health care is provided on
outpatient basis. VHA Model Primary Care Clinics
Be Careful Do more More Policies Do NOT
help providers prevent error or improve
efficiency.
Thanks to JCAHO and VHA initiatives, much has
been done to prevent inpatient errors. We need
to do the same for outpatient clinical errors.
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Therefore,High quality, error-free decisions
requireefficient and effective data access and
analysis

• A clinical error represents
• a faulty decision
• rooted in
• faulty data analysis.
• History, Physical Exam, Various clinical elements

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A Typical EHR is NOT designed

• To prevent clinical errors
• To actively seek out abnormal findings
• To correlate information from multiple areas the
  way clinicians think (e.g., interaction of
  vitals, lab, imaging, etc)
• For user efficiency

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Facts
SupraVISTA addresses all these elements.

• Most clinical errors originate at the point of
  care.
• Most clinical errors occur because the provider
  did not "see" a finding.
• It is impossible to manually analyze all the
  clinical data because of the large volume of
  data in CPRS and the limited time during a a
  clinic visit.

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Impact of systems issues

• Numerous tasks and distractions during typical
  Primary Care clinic visit increase risk of
  missed findings and clinical errors.
• ACA Due to reduced frequency of visits/year,
  more needs to be done on each visit.
• ACA Due to increased RVI a clinical finding
  missed today will not be caught for 6
  months resulting in delayed diagnosis and poor
  outcome.

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Typical Primary Care Visit 8 steps _at_ 4 min/step

• Obtain medical history regarding acute and
  chronic medical problems.
• Perform chart review manual data analysis.
• Perform physical exam.
• Discuss and document clinical findings.
• Write orders and discuss plan with patient (100
  provider order entry).
• Clinical Reminders and EPRP issues.
• Plan and explain follow-up visit.
• Care coordination, answer patients questions,
  fill-out forms

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Why Provider may fail to see an important
finding?
Amount of data to review 50 printed
pages. Clinical findings to evaluate about 200.
(at various locations in CPRS). Average
time to evaluate each finding 30 seconds. Total
time required for an effective chart review
90 minutes.
Time available 4 minutes
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What is SupraVISTA?
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SupraVISTAis a systematic approach to Clinical
Error Reduction
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Fact We simply cannot do it manually anymore.
Todays complex health care environment
Demands a Clinical DSS.
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SupraVISTA complements and enhances CPRS by
adding Clinical DSS capabilities.
Goalprovide all the facilities that a clinician
needs but are not included in CPRS.
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Techo-Talk

• Stand-alone Windows application.
• At heart, a data analysis and reporting tool
• Delphi programming language
• 4 years in development
• 100,000 lines of code (and counting)
• Gets clinical data from a CPRS health summary.
• Provides data security at same level (or better)
  as CPRS.
• Being evaluated to become a Class-I tool.

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It does NOT

• make direct connection with VistA database(s)
  thus it cannot harm anything.
• place orders into CPRS / VistA
• duplicate what CPRS does well
• Cant think of anything else

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SupraVISTA User Interface
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SupraVISTA Core FunctionalityAlerts and Reports
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Sampling of SupraVISTA Tools
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Questions ?