Department of Veterans Affairs

Seeing the Patient’s Picture

Facility: Northport VAMC, NY

Mark L Graber MD – Chief, Medical ServiceLisa Swain – Health Systems Specialist

David Lin MD (Informatics Officer)

Innovation Initiative

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Problem Statement

Despite migration to a graphical interface over a decade ago, our computerized patient record system, CPRS, is largely a text-based record system. We propose to show the patients photo on every CPRS page, an innovation that would ….

Decrease the rate of errors associated with choosing the wrong patient’s record

Be a visual reminder of the need to re-personalize our medical practice Embody the principle of patient-centered care as a core value of our

organization

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Description of Idea

We propose that the patient’s photo should be prominently displayed at the center of the CPRS face page whenever a new patient is selected. Providers would have the option for the picture to fade away after 6 seconds, or remain on the page.

On subsequent CPRS screens the patient’s photo would appear as a small (thumbnail) image on the menu bar.

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Strategic Goals

This project has 3 goals:

1. To decrease the rate of error in choosing the wrong patient New innovations typically invoke ‘surprise’ implementation problems. The tendency to choose the WRONG patient in CPRS is one such problem. The problem arises when providers inadvertently click on the patient above or below the one they wanted from the CPRS ‘pick’ list, or they inadvertently misspell the patient’s name, or mistype the patient’s social security number. The rate of this error is unknown, but it happens to every provider several\many times a year. Once you make this mistake, you are entering orders or notes on the wrong patient, with potentially injurious consequences.

We believe that seeing the patient’s image would make it more immediately obvious that you’ve chosen the wrong patient – the error becomes detectable. The first studies on this effect are just now appearing, confirming that photographs reduce medication errors (http://www.patientsafetymonitor.com/briefings-on-patient-safety Jan 2010).

This project improves the safety of medical care for ALL veterans.

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Strategic Goals - Continued

2. To re-personalize patient care in VHA Our sophisticated electronic medical record system and a growing list of compliance and performance issues all foster a tendency to focus on documentation, at the expense of face-to-face time with our patients. The literature describes this tendency as treating the chart, not the patient. Seeing the patient’s image may serve a valuable role in reversing this problem. We are not aware of research that supports this conclusion directly, but the reverse process (having staff photo’s for patients use) was recently shown to improve patient satisfaction substantially. (Jt Comm J Qual Patient Saf 35: 613-9, 2009)

3. To put the patient at the center of care Patient-centered care is a core value of our organization, perhaps our defining value. Seeing the patient’s photo at the center of the CPRS face page would be a powerful reminder of our goal to put the patient at the center of care..

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Success Metrics

Functional Prototype Success Metric: Sample face pages incorporating the patient’s photo with various options for re-arranging the remaining information will be reviewed with focus groups of providers and patients to obtain a consensus preference. The prototype would be trialed at 4 different medical centers to ensure the product performs as envisioned, before national roll-out.

Expected Results: The final software product will display the patient’s photo at the center of the CPRS face page, and as a menu-bar thumbnail on all subsequent screens.

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Impacts

Veterans Will experience more personalized care Will experience fewer errors related to the provider having

chosen the ‘wrong’ patient

VA Providers Will provide care that is more highly personalized and

patient centered. This will be especially evident when they are working on the patient’s chart in between visits – seeing their patient’s image will help remind them of their patient and their concerns

Will avoid the error of choosing the wrong patient from CPRS lists

Additional support needed Help from VHA programmers will be needed in the initial

design of this software innovation, and its maintenance.

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Technical Approach

All patients accessing VHA services have their photo taken as a registration requirement. Most patients have been photographed or re-photographed within the past 4 years. The photos reside in the VistA imaging application.

We will use the “VIX” middleware patch to allow the two relevant client applications (Vista Imaging; CPRS) to exchange the photo via web services

Once the specifications have been finalized, the team will review the existing Class 3 applications and build on this if possible, or write new code as needed to insert the photos on the face page and the menu bar

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Team and Environment

We have identified the key OIT staff who would be involved in creating the new software needed to implement this suggestion; In preliminary discussions they are enthusiastic about this project, they see it as an easily-implemented, and they have tentatively agreed to work with us an design, testing, and implementation:

Stuart Harris - VistA Imaging Group

Anthony Puleo – CPRS Application Team

This project will also rely on the preliminary work done in our VISN 7 and 20 sites, where they have used home-grown software to show the patient’s picture on the CPRS face page.

Our local environment is supportive and capable. Our Center Director and Chief Informatics Officer have expressed their strongest support for this project, and our Chief Medical Informatics Officer (Dr Lin) is a member of the innovation team. Lisa Swain is a former CPRS coordinator, now serving as a Health Systems Specialist serving the Chief of Staff and Chief of Medicine.

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Implementation

A similar innovation has already been implemented using Class 3 (home grown) software in VISNs 7 and 20. Their product, design elements, and experience would be reviewed to serve as the basis for designing a national implementation. A new middleware product (VIX) will be available to facilitate image transfer into CPRS

Provider and patient focus groups would evaluate different options for how to display the patient’s photo on the face page, and how to-re-arrange the page’s other content

The design team for the national implementation would meet to review this information and finalize design plans, intermediary goals, and the final timetable

The national team would work with and supervise the software creation to implement the photo displays

The prototype would be trialed voluntarily at 4 medical centers who are not currently displaying the patient’s photo. The prototype would be evaluated for appearance, functionality, aesthetics, and problems.

After any necessary revisions, the product would be released nationally

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Timeline

    Q4 - 2010 Q1 - 2011 Q2 - 2011 Q3 - 2011 Q4 - 2011

Step 1 Review the Class 3 implementation          

Review prototypes with focus groups          

         

Step 2Agree on plans for the national implementation          

         

Step 3 Software creation          

         

Step 4 Prototype evaluation at 4 VA's          

         

Step 5 National implementation          

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Budget Narrative

The main cost of this project is the programmer’s time to develop the software. The images are all available. Stuart Harris has estimated the developer time needed to be approximately 1 month.

We anticipate no direct costs for any of the other steps. Planning meetings can be held via teleconferencing, focus groups will be done without costs, and national implementation will be announced at no cost at the VA CPRS users conference and by email announcements

The planning team has sufficient time allocated in their normal tour of duty to work on this project as necessary

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Challenges & Risks

Risks: We see no definite risks other than the unknown challenge of developing appropriately functioning software

Challenges: The picture may be out of date and may not be an ideal representation of the patient if they have lost\gained weight, or have lost their hair, etc. We may need to give patients an opportunity to have an updated photo taken in these circumstances.

Opportunities: If the innovation works to decrease errors, a next logical step would be a similar implementation for our bar-coded medicaition administration program. Seeing the patient’s photo may help decrease medication errors – it’s another mode of identification that would supplement the 2 items required by the Joint Commission and VHA.

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Mock-up of how a CPRS screen would appear

CPRS Face Page

All other pages

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What Do You Really think?

This ‘innovation’ is a no brainer. Its already working well in several sites, and it should have been implemented at the national level a long time ago !

Seeing your patient’s image should be a basic requirement of EVERY electronic medical record system.