1. Radiology
Judy Iskandar, RTR

2. Objectives for this Session
Finishing the Radiology order in RPMS
Process Changes
Pros and Cons

3. Registering the Patient in the Radiology Package
Radiology orders are printed to the printer when the physician places the order
All pts are registered for an exam. This assigns a case number, allows technician to review the order and complete any missing information, and
prints the flash cards and exam labels

4. Registering the Patient in the Radiology Package
This gives the technician an opportunity to add the procedure modifier which may have been omitted from the order

5. Entering the Exam Entering the exam information:
LMP (frequently omitted)
Technologist name
Film Size
ETC

6. Radiology Reports in EHR
If a facility is uploading the results, they will display in EHR
When vista imaging is deployed, the image will display in EHR

7. Process Changes Using RPMS Radiology Package
Providers order the exam electronically
Radiology orders print out automatically

8. Pros and Cons LMP? Modifiers?
EHR prompts for PREGNANT or NOT PREGNANT. It prompts for LMP on the wellness tab and this doesn’t cross over to RADIOLOGY ORDER. We ask our providers to put the LMP into the History and Reason for Exam
LMP and Modifiers may be omitted from the order. This is a training issue

9. Questions?

10. Practical Transition and Practice: The Pharmacy and EHR
CAPT Steven C. Doane
Chief Pharmacy Services

11. Elements of Transition
Clinical Transformation
The redesign of clinical process involving the adoption of information technology
Fundamental Changes
New business model for health care
Pharmacy/clinic workflow
Mental process changes – paper to electronic
Planning/Preparation
Standardization
Staff Preparation
Planning/Preparation– do not underestimate the time and effort to prepare for the Electronic Health Record or for adapting to transformed ways of conducting business.

12. EHR/Pharmacy Goals
To make patient data available across the spectrum of care
Improve the care provided
Improve the efficiency of care
Improve patient safety
Maintain and/or expand pharmaceutical care practice

13. Preparing the Pharmacy

14. Personnel Assess ability to accept and handle change Problem solve
Address concerns and issues
Adapting as the process evolves
Creation of new procedures – some transitional
Involve staff
Make assignments to accomplish tasks
Training and communication
Staffing levels and placement

15. Equipment - 1 Review current department status
Availability of computers/workstations
Staffing ratio and availability to equipment
Type of terminals
Number of workstations
Placement of workstations
Age of equipment and terminals
Availability and placement of printers and automated counting equipment

16. Equipment - 2 Needs Assessment for EHR/Ver. 5/7
Computers/workstations and work areas
Placement of equipment for effective operation
Need for multiple points of entry?
Expense to upgrade systems
Ability to maintain systems
Placement of personnel
Electronic signature capability?

17. Workflow - 1 Transition phase Future processes
Maintaining continuity and safe practice
Managing two systems simultaneously
Map workflow: present and anticipated
Future processes
Managing patients and prescriptions without a physical chart
Processing prescriptions: Assurance of accuracy, safety, verification, etc
Process for documenting interventions and notes
Pharmacists finish – Technicians fill?
Patient signature capture – changes?

18. Workflow - 2 Policies and Procedure Review Patience Standardization
Uniformity – electronic systems highlight weaknesses in operation
Managing CII prescriptions
Managing “outside” prescriptions
Providing the insurance audit trail
Patience
Allow time to adjust, adapt, and evolve to new practice and business model
Allow time for pharmacy preparation prior to EHR – Familiarity with Pharmacy RPMS Version 5/7

19. Practice Considerations and Best Practices

20. Finishing the Prescription
Prescription order transfers from EHR to pending file on pharmacy prescription screen
Pharmacist involvement and intervention
Opportunity for pharmaceutical care
Review process
Cover sheet for ADR and other key data
Provider notes
Review prescription and make changes
Send for filling

21. EHR Prescription Orders -1
New orders
Use of quick order lists
Individualize for facility
Make quick orders for key drugs and dosages
Consider multiple refills
Renewal
Pros
quick
No changes in previously written prescription
Cons
Inability to modify Rx
Previous errors will remain
Do not used until on 5/7 for period of time

22. EHR Prescription Orders -2
Refill requests
Benefits
Can be prompted to pharmacy from EHR
Shows up as “refill request” in pending file
Processes similar to other refills
Problems
What if refill is too early?
Process, hold, pending file, or discontinue?
Cannot undo request

23. Partial Fill Function Advantages Disadvantage
Can fill limited amount based on previous prescription order
Does not affect order with refills currently in system
Disadvantage
Does not show on patient profile
Consideration of policy change
Provide for multiple refills (up to 1 year)
Decreases workload for pharmacy
Decreases partial fills
Decreases changes to current prescriptions which affect provider’s efficiency with EHR

24. Hold – Unhold Function
Used to place a prescription in a hold category for further/future follow-up
Common use – placement of an order on the system until next or additional refills needed by patient
Can edit prescription when released from hold
Problematic
Individual sites need to set standards for use
Overwrites current prescription items
Providers cannot affect held prescriptions
Can write comments, but only visible through EHR

25. Return to Stock and Reissue
Previous Prescription(s)
Adds additional refill to the prescription
Process reissues by refilling
Original Prescription(s)
“R” Designation given
To Reissue
RP – Reprint prescription(s)
Edit Fill Date (optional)
RL – Release prescription(s)
Problem
Retains original fill date on the reissued prescription and profile unless changed

26. Paperless Refill Simple process to turn on and use
Consider workflow changes
No progress notes, PCC(s), etc.
Direct patient interaction
Procedure
Select drug(s) to be refilled
System asks for POV on each drug
POV chosen from sequence of 3 lists – Problem list, POV list, then free text narrative entry
Prescriptions print as previously
Refill line prescriptions are handled similarly

27. Documentation Pharmacy Note Education Coding
When? Each refill, significant interventions, other?
How? Free text, template, other?
Education Coding
Where? Wellness Tab
When? Complete patient education prior to a note
How? Select education topic, level, plan, time
Create visit if different day than original provider visit
Add name as a provider
No POV usually needed except for counseling V68.1
Can create POV pick list to aid in process

28. Christopher Lamer Grant Rogers
Implementation
Christopher Lamer
Grant Rogers

29. New Terminology POE – Provider Order Entry CAC – Clinical Application
Coordinator
GUI – Graphical User Interface
OE/RR – Order Entry/Results
Reporting
PIMS – Patient Information
Management System
TIU – Text Integration Utilities
Server side applications – roll and scroll; back end applications
CPRS – Computerized Patient Record System
VueCentric Framework
Vista – Veterans Health Information System & Technology Architecture

31. Leadership, Commitment, Buy-in
Confirmed Leadership support
Tribal Endorsement
Area Office Support
Patient Awareness
Clinician driven

32. Force Analysis What factors will encourage EHR implementation?
What EHR implementation barriers exist?

33. Hire a CAC
The incumbent is responsible for the implementation and support of multi-service software packages that automate the capture of clinical encounter information and its subsequent retrieval. The application coordinator manages the customization of the site parameters and addresses integration issues with other software packages. The incumbent assists in the implementation of new software products obtained by the facility that cover these functions.
Analyzes and evaluates processes related to information flow and serves as liaison between service lines concerning these processes…Assists staff in the efficient use of the current software.
Provides training to clinical staff … emphasizes timeliness, accuracy, security and the importance of these functions on every other clinical application. Coordinates classes with IRM training section and serves as backup for basic training classes.
Incumbent promotes an awareness of the importance of data validity and data security and coordinates efforts to correct deficiencies and errors that occur in the electronic record..,provide secondary support on related software modules…

34. Develop training plan for CAC
Training for CAC & Implementation Team,
Basic Site Manager,
Fileman,
PCC Outputs,
Lab Package,
Radiology Package,
Preparing Pharmacy for EHR
Advanced EHR trainings,
Site Visit to EHR site
Training Site Webpage

35. Implementation Team
Clinical Champions from each discipline (Lab,RN, RPh,MD,etc)
Administration/Executive Leadership
Information Technology
Include Area IRM representation
Clinical Application Coordinator
Have well rounded teams.
Clinical Super Users (rn, rph, lab,dm,md)
Training
Peer Support
Templates optional
CAC :
Portland and Indianapolis VA 1 CAC for each 250 users
The CAC is a new, specialized position separate from Network Specialist, CIO, User Support
Sample Positions descriptions on EHR Website
Works cooperatively with Site Manager
Coordinates Implementation
EHR User Support
Customize Software
Workflow
Clinical Background
RPMS experience
Project Management /Leadership Skills
Facility Working Process Knowledge
Computer Skills

36. Implementation Team Roles
Identify and define Policies and Procedures
Address staffing and scheduling during transition
Peer Training & Marketing
Monitor and Execute Implementation Plan
Design and Approve templates, menus, and ordering lists for E.H.R.
Here are some of the roles the team should play.

37. Hardware Evaluate current hardware needs Evaluate network needs
Begin procurement process for hardware
Hire additional IT staff if necessary
Install new equipment and test it before using

38. Upgrade Hardware/Infrastructure
RPMS server
Training server
Network
Lab Interface Upgrade
Workstation Access - Everywhere
Backup Power

39. Assess utilization of RPMS "Point-of-Service" packages
Assure packages are being used correctly before going to EHR
Immunization 8.0,
Women's Health,
Diabetes Management,
Behavioral Health System v3.0,
Behavioral Health GUI,
Dental, and
Case Management
Implement or assure correct usage to appropriately capture required data.

40. Identify go-live clinic or location Address staff concerns
Identify all affected staff: lab, pharmacy, nursing, radiology, medical records…
Schedule an overview of EHR training
Publicly promote the EHR implementation
Discuss with all parties: hospital, tribal, labor union, etc.

41. Setup Implementation Plan/Timeline
Example of a project plan
Very helpful to keep everything on track.

42. Another example from the EHR site

43. Implementation Strategy
Implementation-Who and When
Everyone at once - one at a time?
Lab ordering , then radiology ordering, then pharmacy ordering, then notes
Bring up one team/dept at a time
There are different strategies – some are more painful than others.
Sacaton-everyone at once
Whiteriver-lab ordering, then radiology
WSP-staggered –one dept at a time.
Each system has merits and drawbacks.
It was difficult to have a paper system and an electronic system because there are different processes for each type of system
It can be overwhelming to have everyone at once

44. Implementation Sample Schedule
This was our schedule.
Teams consisted of provider, nurse and nurses aid.
Daily debriefings? (talked about some were less I think)

46. Document Plans
Assess risk and effects of initial changes in productivity
Develop contingency plan
Provide area office with a copy of implementation plan

47. Prepare for Installs Review CAC and User Guides
Coordinate with consultants
Prepare a plan for providing staff with training on new RPMS packages

48. Graphical User Interface (GUI) Electronic Health Record
Update Your Software
Site RPMS System
Baseline applications: Cache (FM22, F200 conversion, K8), Laboratory v5.2 p17, Radiology v4.0/4.5 p10, Outpatient Pharmacy v6 p5, Pharmacy Inpatient Suite v4.5, Immunization v8.0 p1, Women’s Health v2 p9, Patient Chart v1.4 p1, Patient Registration v7.0 p4, MAS v5, p8
Current patches of the following: AUT, AUPN, ACPT, AVA, XB; (ER package)
PIMS 5.3
patched to support CPRS v20
Radiology v5.0
(requires PIMS 5.3)
Lab v5.2 p18
TIU v1.0
Ancillary Packages
Pharmacy Data Management-
PSS v1 p1
Part of EHR suite:
Dietetics 5.0
Nursing 4.0
Surgery 3.0
Medicine 2.3
Problem List 2.0
I/O Package 4.0
Vitals 5.0
Scheduling GUI (9/30/04)
Vista Imaging v3.0
(Optional)
(Requires Radiology 5.0)
IHS-EHR
Graphical User Interface (GUI) Electronic Health Record
Pharmacy Package (OE/RR 3.0 Inpatient Pharmacy 5.0, Outpatient Pharmacy 7.0, Consults 3.0) with PSG mods
Controlled Substances 3.0, Drug Accountability 3.0, Auto Replenishment 2.3, Pharmacy Benefit Management 3.0, BCMA 2.0
Electronic Health Record Functionality
Clinical Queue, Services tab, Provider POV, Health Maintenance (Wellness), Nursing triage, CPT codes, Problem List, Immun.
- VA Lexicon v2.0
- VA Health Summary v2.7
- Visit Tracking/PCE/ Clinical Reminders (requires PIMS 5.3)
PCC Data Entry v2.0 P7
Fileman 22 (1002), HL7 v1.6 p1005, Kernel Toolkit v7.3 p1002, Kernel v8 p1009
- Integrated Billing 2.0
- Auto Info Collection Systems 3.0
- Generic Text Generator 3.0
Kernel 8 (1010), Mailman 7.1 p1004 patched to support CPRS v20

49. PIMS
Patient Information and Management System
Scheduling
ADT
security

50. Begin Work flow Analysis and Business Processes
Follow the paper chart from patient registration to the billing office
What processes will change with EHR?
What processes will not work with EHR?
Make sure everyone is on the same page!

51. PCC
Patient
Database
Patient Registration
Data Entry
Coding
Patient Visit
Pharmacy
Lab
Billing
Radiology
Case Mgt
Key
Paper Flow
EHR Flow
Common Flow

52. Ballpark Timeline PIMS install Radiology 5.0 install – after PIMS
EHR-Pharmacy 5/7
Needs to be scheduled
Requires several months of preparation
Pharmacy needs to be used 3-6 months before implementing medication order entry.
Installation of GUI client - After Pharmacy
EHR Set-up
Go-live – 3-6 months after Pharmacy

53. Lab Preparations All Labs need to be entered in RPMS
On-site Labs
Reference Labs
State Labs
Computer Access Points
Changing from Esig to EHR
All labs so that they can be ordered in EHR
Replaced Wyse monitors with thin clients
Quit using the lab esig and signed abnormal and critical labs in EHR notifications

54. Pharmacy Preparation Pharmacy preparation can take up to 2 months!
Adverse drug reactions month
Provide GMRA key to data entry to document allergies and adverse reactions
RPMS/Scriptpro Format days
Dosages in Pharmacy week
Quick orders week

55. EHR Configuration Quick Orders Design templates
Design Menus and Quick Orders
Meds, Labs, Radiology, Nursing
Define consults
Pick lists for ICD9CM & CPT Codes
Note Titles
User Setup (keys)
Parameters
Printing Chart Copy and Orders
Print Formats
This is what you need that 3-6 months for!!!
The VHA came and helped us with templates, orders, consults
Orders need to be created locally by pharmacy and cac
ICD and CPT pick lists (superbills) can be imported from other sites
Templates can be imported from other sites
Template training: Manning,Rudd, Koepping, CST makes templates
Like pcc+ this can be a rate limiting step

56. EHR Before Configuration
Before order menus

57. EHR After Configuration
After order menus
These can’t be copied from other facilities. (bummer)
It is very important to have as much setup as possible – this will decrease you providers time ordering and stress level.
This was large part of our Success!!!

58. Medication Quick Orders

59. Lab Quick Orders

60. Templates

61. Go Live Week 4-6 hours training outside of clinic
Departmental Trainings
Use Knowledgeable Trainers (IHS/VA)
One-On-One Training Also
Competency Checklists

62. There is no-where safe to hide!
Going Live Week
There is no-where safe to hide!

63. How the Week First Goes Growling at CAC’s Cat in the microwave TGIF
Crying, gnashing of teeth
Monday – have a ½ day of training, then out to the clinic to see 2 patients
Tuesday – they expect us to what??? See a patient every 30 minutes, impossible
Wednesday and Thursday – Wondering why
Friday – TGIF – things are looking better
Excited

64. Going Live Intense CAC and IT Support
Make Appropriate Scheduling Adjustments
Daily Debriefings….
Procedural Questions
Technical Issues
How did it work before EHR?
More Training
We had 2 outside CAC’s come and help with all the questions in the clinic. It was a big help
Changed from 15 min appts to 30 min appts for 2 weeks
Then to 20 min appts – we still have 20 min appts.

65. Miscellaneous Policies/Procedures
Use of personal templates
Template approval process
Use of chat and broadcast

66. Things to Think About Referral / Consults
Patient Registration: Centralized / Decentralized
People who aren’t using E.H.R. yet- how are they handled?
Handle the missing PCC elements? SHX, colonscopy, refusal,mammogram (offsite)

67. Medical Records Process
When to stop pulling the chart
Filing notes in chart?
Print And File Chart Copies? Batch Print?
Release Of Information?
Outside Consults? Scanning?
Incorrect Entries?
How will they handle the change?

68. Impact on Staffing Provider support during implementation
Future plans to shift staff from Medical Records to other locations (clinic)
Relax provider schedules during implementation
Staff shifts: - 9 months after implementation
2 staff from medical records are cleaning up pcc errors
1 medical records technician is a nursing aid
1 medical records technician is a benefits coordintor
4 nurses aids before EHR implementation and now we have 7

69. What does EHR cost? Or… How much do you have?
Really What doe EHR Cost????
Or… How much do you have?

70. What goes into costs? Hardware Network Additional staff
Servers, computers, peripherals
Network
Wireless, LAN, Servers
Vista Imaging, Meuse
Additional staff
Additional time
Emotional distress
Loss of friends

72. Questions?