To Study The Functioning Of VistA CPRS

Project OverviewJune 2012

Dr. Amit Kumar Srivastava

Dr.Garima Malik

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Country’s leading comprehensive provider of standardized, seamless and international class healthcare services

It is committed to the highest standards of medical and service excellence, patient care, scientific and medical education

Max Healthcare operates eight facilities in Delhi & NCR, offering services in over 30 medical disciplines

Max Healthcare has a base of over 1600 leading doctors, 4300 employees and 13,00,000 patients with number of beds growing to over 1900 in the next two years

Organizational Overview

MAX HEALTHCARE

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GENERAL OBJECTIVE:

To Study the functioning of VistA CPRS

SPECIFIC OBJECTIVES:

To study the workflow involved in the module CPRS

To identify the relationship of the CPRS with other modules of VistA

To reach a comprehensive training plan to the hospital customers

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SCOPE OF STUDY:

To study CPRS in depth, so that will be able to assist end users ( nurses & physicians) while giving hands on training

Study can be used for creating user manual, training plan and schedule

Observational

Interview of end users with close ended structured questionnaire

METHODOLOGY:

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CCPRS/BCMA HANDS ON TRAINING

TO DESIGN AND PLAN SCHEDULE FOR TRAINING PROGRAM

TRAINING END USERS

REFRESHER SESSIONS

PROJECT REPORT DRAFT

APRIL 9TH-13TH

APRIL 16TH- 20TH

APRIL 23RD-27TH

APRIL 30TH-MAY 4TH

MAY 7TH- 11TH

MAY 14TH- 18TH

MAY 21ST-25TH

MAY28TH-31ST

JUNE 1ST- 13TH

SUMMER TRAINING PROJECT TIMELINE

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VistA

The Veterans Health Information Systems and Technology Architecture (VistA)

It is an enterprise-wide information system built around an electronic health record, used throughout the  U.S. Department of Veterans Affairs (VA) medical system, known as the Veterans Health Administration(VHA)

VistA, is an integrated system of software applications that directly supports patient care

It has various modules, some of them include laboratory, pharmacy, radiology, Bar Code Medical Administration and CPRS

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VistA CPRS

It is graphical user interface for clinicians known as the Computerized Patient Record System (CPRS), which was released in 1997

It allows health care providers to review and update a patient's electronic medical record

It includes the ability to place orders, including those for medications, special procedures, X-rays, nursing interventions, diets, and laboratory tests

It provides electronic data entry, editing, and electronic signatures for provider-patient encounters as well as provider orders

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VistA CPRS in Detail

VistA – Veterans Health Information Systems and Technology Architecture computer application

CPRS – Computerised Patient Record System

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CPRS

To enter Patient

Information

To review Patient

Information

Continuously Update

Information when

connected.

Supports Clinical

Decision Making

Analyze Patient Data

PURPOSE OF CPRS

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Record Patient History

Enter Problems

Enter Diagnosis

Enter Treatment Plan

Enter Progress Notes

Record Allergies

Record Adverse Events

Request and track Consults

Order Lab Investigations

Order Medications

Order Diets

Order Radiology tests

Order Procedures

Enter Discharge Summaries

CPRS Helps To

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COMPUTERISED PHYSICIAN ORDER ENTRY ( CPOE )

CPOE decreases :-

1. Delay in order completion

2. Reduces errors related to handwriting or transcription

3. Allows order entry at point-of-care or off-site

4. Provides error-checking for duplicate or incorrect doses or tests

5. Simplifies inventory and posting of charges

Salient Features of VistA CPRS

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BENEFITS OF CPOE

a. Enables doctors to enter prescription, lab test and other orders for patient care straight into a hospital information system

b. CPOE decision support includes: automated medication checking, drug dose, allergy, and interaction checking; duplicate order notification; recommendations for pre- or post-administration tests etc

Adverse Reaction Tracking

a. Documents patient allergy and adverse drug reaction data

b.Alerts the Pharmacy and Therapeutics Committee each time the signs/symptoms are modified for a patient reaction

Clinical Reminders

a. Allows clinicians to resolve reminders through dialogs within the CPRS GUI (graphical user interface). Using point-and-click techniques, a clinician can generate text for progress notes, update current and historical encounter data in Patient Care Encounter (PCE), update vital signs, update mental health test results/scores, and place orders

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Difference in Workflows before and after EHR Implementation in Client’s Hospital

Orders are sent manually

Billing – Pre Consultation Billing

Patient gets Prescription from Physician

Manual Medication Administration to IP patients

Trade Names of Medicines Prescribed

Orders will be send electronically

Billing – Post Consultation Billing

Patient will collect the Prescription from the front

desk after making the payment for consultation

Bar-coded Medication Administration

Generic Names of Medicines Prescribed, New Concept of Cart fill and Unit Dose to be

introduced

Before EHR Implementation After EHR Implementation

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TRAINING – PLAN AND SCHEDULES

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TRAINING NEED ANALYSIS

To get the information of number of end users to be trained

To know who are to be trained in which module that is CPRS, Radiology, Lab and Pharmacy and what will be the staff number for the training

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ROLES AND RESPONSIBILITIES OF THE TRAINING TEAM AND THE USERS

End User• They should be familiar with the working of the system

• They should be able to access, retrieve and enter data in VistA

• They shall be well versed with the module

Training Coordinators• They will coordinate the entire training process

• They will check availability of trainers , staff , training material and infrastructure

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BASIC METHODS OF DELIVERY

1. Individual hands-on Instructor

An instructor walks to each user individually to help in performing common tasks and clear their doubts.This is the most expensive method, although potentially the most effective.

2. Hands on class room style instructor-led training

An instructor shows users how the software works and how to perform common tasks, with users performing the tasks themselves in a classroom/lab setting. Each user or pair of users will have a system to practice the software. Classes of 12-15 are often effective.

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3. Seminar Style Group Demonstration

An Instructor shows users how the software works and how to perform common tasks in a live demonstration. Groups of 20 to 50 are often effective.

4.Computer Based Training

CD-based or online ( Web Based )

Self-placed training allows end-users to complete interactive lessons, as per their comfort and this makes them efficient in performing common tasks . The software tests them on their performance and understanding.

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4. Most of the providers were not happy with the amount of data entry and the time consumption

3. Problem was faced regarding time management as a lot of physicians were not able to come on time during the training

2.There were issues of change management as some providers felt that paper based system was better

1. The senior physicians were not co-operative and were not satisfied with the new system

CHALLENGES FACED

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RECOMMENDATIONS

The senior physicians should be counseled again and advantages of the paper less system should be explained to them to develop a positive attitude

Training should be scheduled such that during that time they don’t have to see any patients and there duties are taken care of by some other person

Location and time of the program should be such it is comfortable for the people who have to attend

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CASE STUDY (1)

Physician Perception on Electronic Health Record

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OBJECTIVE:

To Study the Physician’s Perception on EHR

METHODOLOGY:

A sample size of 30 Physicians were taken to evaluate their perception of the CPRS/ EHR

Only the physicians who have undergone 16 hours of hands on training were considered

Out of them 30 were randomly selected

A well structured questionnaire in english was used for the purpose of primary data collection

The questions were related to computer awareness as well as EHR

Physician team covered were : Junior Residents, Senior Residents, Specialists, Consultants

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OBSERVATIONS

64.7% of the Physicians who were sound with the computers felt that the new EHR will increase workload and entering data will consume time

100% of the Physicians are aware that the EHR implementation will reduce medication errors and agree that EHR supports effective communication among team members.

66.7% of the Physicians were not satisfied with the training they received on CPRS

66.7% of the Physicians feel that the EHR is not user friendly

8 Physicians who were sound with computer skills felt that the EHR application is not user friendly

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RECOMMENDATIONS

More change management efforts should be made so that the physicians develop a positive attitude

The templates for entering case history can be made simpler

Free text option can be given for entering case history

Before initiating the CPRS training an orientation process should be carried out regarding the entire EHR process

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Comparative Study Of Paper Medical Records & Electronic Medical Records

CASE STUDY (2)

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OBJECTIVE :

To do a comparative study of the Paper medical records and the Electronic Medical Records

METHODOLOGY:

Observational & Discussion method

The information is collected primarily by observation of the software and making a comparison between paper medical records & electronic medical records.

Focus points of discussion are:

• Disadvantages of PMR

• Advantages & EMR over PMR

• Disadvantages of EMR

• Also some information is collected using secondary data sources

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OBSERVATION: PMR VS EMR

• Patient is identified by name, medical record number & other identifier

• Progress notes might be produced by dictation, free handwriting or form completion

• Consists of office or progress notes in chronological sequence. These are browsed by literally flipping through pages, until the desired entry is located

• Prescription is written on paper. It is manually checked for interactions & allergies. It is then taken by the patient to the pharmacy .It takes time & can also result in errors

• Patient can be identified by any identifier i.e. Name, SSN, Date of birth, phone number

• Progress notes are produced as the visit is produced

• Stores progress notes and provides quick access by date of visit, provider and the ability to browse by diagnosis and prescription

• Prescription is written in the system. It is checked for interactions & allergies by the system & then it is sent to the pharmacy by the system directly where it is verified & drug is dispensed. There are rare chances of errors.

PMR EMR

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DISADVANTAGES OF PMR

1. Needs lot of space for storage

2. No centralization of records & collection of records is a tedious task

3. More chances of medical errors caused by poor legibility on paper forms

4. Less in efficiency as compared to EMR

5. Data cannot be easily exchanged or transferred

6. They are not eco-friendly

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ADVANTAGES OF EMR

1. Increasing storage capabilities for longer periods of time

2. Is accessible from remote sites to many people at the same time

3. Retrieval of the information is almost immediate

4. The record is continuously updated and is available concurrently for use everywhere

5. Information is immediately accessible at any unit workstation whenever it is needed

6. Provides medical alerts and reminders

7. Supports accountable autonomy, collecting and disseminating information to assist the medical professional in decision making

8. Allows for customized views of information relevant to the needs of various specialties

9. Provide information to improve risk management and assessment outcomes

.

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1. Start-up cost is high

2. Lack of Technical knowledge

3. Inability of the provider to adapt

4. Usability is a major issue

5. Placement of hardware is an issue

6. Crashing of computer & loss of data

7. Change in workflow of the department after the implementation of an EMR

8. Lack of standardized terminology, system architecture, and indexing

9. Lack of flexibility and lack of capacity for the diverse requirements of the different healthcare disciplines

DISADVANTAGES OF EMR

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RECOMMENDATIONS

• The robust back up methods, sophisticated protection mechanisms & advanced data recovery methods should be developed

• Decisions regarding the portability of the equipment must also be considered

• Documentation forms must be revised in order to accommodate the changes in the workflow

• Development of standard language is required

• A unique health identifier must also be developed

• Well planned training must be given to the end users

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THANK YOU