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					#258-Women Veterans Health
           Care
      the “XX Files”
  Peggy Mikelonis ARNP-C, MS, CNA
               Tampa
      Cheryl Knowles RN, MSN
          Canandaigua/Bath
       Kathy Prividera RN, MS
               Albany
                OBJECTIVES

• Present brief overview of history of
  women in the military
• Address women veterans using VA
  health care system
• Apply functionality in CPRS to
  facilitate the delivery of care to
  women veterans
  – From national to local level


                                         2
            WOMEN VETERANS

• The important role of women in our nation’s
  defense and as part of the veteran
  population over the years cannot be over-
  stated
• Women now comprise 17% of active duty
  deployed forces- and are becoming veterans
  at an increasing rate
  – During Gulf War I (1991) Women were 10% of
    Deployed Active Duty, 5% of forces overall
  – From WWII- Vietnam era, women comprised
    between 3-5% of Active Duty
                                                 3
4
           Women’s Health Moves Forward

• Dr Kussman approved change from Women
  Veteran Program to Women Veteran Health
  Strategic Healthcare Group- March, 2007
• Moves focus beyond gender-specific care
  such as Pap Smears to comprehensive care
  of women- and women’s health as a
  subpopulation of all veterans
• Increase focus on quality of care issues and
  comprehensive longitudinal care for women
  veterans


                                                 5
Women Veterans Using VA




                <Age 45
                Age 45-65
                >Age 65




                            6
      DEMOGRAPHIC DIFFERENCES

• Women VA users are younger
  – Mean Age 49.5 years
• Men: Mean age 70 years
• Women users have more education
  (65% have college, 35% of males
  users do)
• Less likely to be married (25% of
  women, 48% of men)

                                      7
8
                                   VA Women Veterans
                450000



                400000



                350000



                300000



                250000



                200000



                150000



                100000



                 50000



                     0
                          1999     2000     2001     2002     2003     2004     2005     2006

Women Veteran Patients    142511   154356   171161   182434   195516   207861   223764   237499
Women Veteran Enrollees   194374   226021   275316   304989   330904   352128   379549   404613

                                                                                                  9
             THE NEW XX FILES

• National
  – Women’s Health Software
  – Military Sexual Trauma (MST) Software
  – WVSHCG Website http://vaww1.va.gov/wvhp/
• VISN
  – Osteoporosis
  – Pregnancy/Lactation Flag
• Local
  – HPV vaccine
  – Templates for gender specific exams

                                               10
Presenter: Peggy Mikelonis ARNP-C,MS, CNA
• Master’s prepared ANCC certified Adult Health
  Nurse Practitioner employed at the Tampa Veterans
  Hospital.
• ANCC certified Nursing Administrator
• Has been working in the area of women’s health
  specifically since 1993 (been at Tampa many years
  before in variety of nursing roles).
• Presently is the Lead Women Veterans Program
  Manager for VISN 8 and the WVPM for Tampa.
• Actively involved in women veterans health
  program development, assessment and
  implementation at national, VISN and local levels.
• Recipient of the Dept of Veterans Affairs Fourth
  Annual WVPM of the New Millennium Recognition
  Award(2004)
                                                  11
    Additional Presenter: Kathryn W. Prividera, MS, RN

•   Master of Science: Community Health CNS & Gerontological Nurse
    Practitioner.

•   Lead Women Veterans Program Manager VISN 2 -1996-2007

•   Women Veterans Program Manager Stratton VAMC, Albany since
    1994

•   Actively involved in development and implementation of Women’
    Health Software; MST software; and Integration of Women’s Health
    software with CPRS having served on the National Tags' for all of
    these initiatives.

•   Member of Team CPRS/WH Integration Usability Testing CAMP
    CPRS 2003.

•   Total nursing experience >43 years

                                                                        12
           NATIONAL WOMEN VETERANS
               HEALTH SOFTWARE

• Optional software for sites to utilize
• Every site must install the new clinical
  screening reminders whether they use
  this software or not.
• Screening reminders designed to work
  for all sites, whether they use the WH
  package or not (NATIONAL)



                                         13
• Each site needs to decide whether review
  reminders should be installed and released
  to the staff

• Review reminders facilitate
  – Sending WH results letters
  – Updating WH needs due dates so WH reminder
    letters can be generated



                                                 14
             Military Sexual Trauma (MST)
                       Screening

• VHA Directive 2005-015 outlines the MST
  program (dated March 25, 2005)
• MST national software
  – Allows tracking of VA’s screening of veterans
• MST Coordinator at every VAMC
  – Ensure all enrolled veterans screened for MST
  – Provide staff education and training
• MST Resources website
  – http://vaww.collage.research.med.va.gov/collage/
    E_behav/MST/


                                                    15
MST Reminder Resolution




                          16
              MST Status

• MST status is dynamic and can be
changed
• Example:
   – A veteran is screened in primary care and
     denies any MST experience. Later, the
     veteran discloses their MST to their
     mental health care provider.
•In order for this veteran to be eligible for
free
 care, you must change the MST status
                                             17
           How to Change MST Status

1. Open the veteran’s medical chart in
   CPRS
2. Begin writing a progress note
3. Open the “Reminders” drawer. You will
   see any reminders that are currently
   due.
4. To access old reminders, click on the
   “Applicable” folder.
5. Open MST screening
6. Mark “yes”                            18
3. Open the “Reminders”
         drawer




                          19
4. Click on the “Applicable”
           folder




                               20
5. Open MST Screening




                        21
6. Mark “yes




               22
        Impact of Changing MST Status


• This will change the reminder record
  AND the encounter form for each visit
  will now ask whether service provided
  was MST-related
• Very important: visit must be marked
  MST related on the encounter form for
  the veteran to receive free treatment
  and record that MST treatment was
  provided
                                      23
Noted on the encounter form




                              24
Using Patient Record
Flags in Women’s
Health
             Why Have a Patient Record Flag for
               Pregnancy/Lactation Status ?


• Pregnancy and/or lactation status in CPRS

• Medication management and safety for women
  who are pregnant or breast feeding

• Reminder reports every 3
  months/Documentation in CPRS

• Summary report of all patients assigned the
  flag.
                                                  26
        Flag implemented and maintained by
                    the WVPM

• Identified responsible person
  – designates an alternate
• Coordinates care with Fee Basis Office
• Assigns patient record flag
  – Menu assigned by Health Administration
    Services
  – Menu includes
    • Record Flag Reports, Record Flag Assignment
      and Record Flag Management

                                                27
        Step One: Set the Flag

After determining who is appropriate
 for this record flag, you must first
 use your VISTA menu options to
 set the record flag:




                                        28
Select the patient




                     29
Assign the flag




                  30
Select the Flag




                  31
Select a flag for this assignment: L.PREG PREGNANT OR LACTATING
   ACTIVE       CLINICAL
     ...OK? Yes// (Yes)
Enter Owner Site: SYRACUSE VAMC//         NY VAMC 528A7
Approved By: PRIVIDERA,KATHRYN W            KWP  11W    Women
   Veterans Program Manager



      At the „Approved By:‟ prompt, enter your name.




 In this field you type something very brief:
 Please use care when prescribing or filling prescriptions for this
 pregnant patient.


                                                                      32
You must define the
review date, which is
defaulted to 90 days.
You are then shown a
summary of what you‟ve
just done.




                        33
Once you say YES to this prompt, the flag is set.




                                                    34
                  Display to Providers in
                 Radiology and Pharmacy


Do you want to continue processing this patient record?
No// yes (Yes)
>>> Active Patient Record Flag(s):
     <PREGNANCY LACTATION STATUS>           CATEGORY
II
Do you wish to view active patient record flag details?
YES//



                                                          35
36
STEP TWO: WRITE THE NOTE




                           37
Note: this is a special title that needs to be associated with a flag.
You must click on the flag that appears below the title listing.

                                                                         38
The title is connected to
this template.
When writing the note,
click in the appropriate
boxes.
All boxes have been
clicked in this example
so that all choices are
evident.




                       39
40
Here is the flag as it appears
when the patient is selected in
CPRS:




If the user clicks on the note
listed in the lower box, the
electronic progress note
appears.




                            41
                 STEP THREE: REPORTS




You have also been given the Record Flag Reports Menu.




                                                         42
43
            This is the flag assignment report for all patients with this flag.




Note: This software is not multidivisional, so the only way you can
separate the patients by site is by looking at the “Owning Site”.


                                                                          44
The report option “Assignments Due for Review Report‟ will
tell you who needs to have their flags reviewed in the future:




                                                            45
This is the report, showing that the patient‟s flag is due for
review on March 11, 2007.




                                                             46
         Renewing, editing or removing the
                       flag:


• Record flags must be reviewed on a
  periodic basis. The Pregnancy
  Lactation flag is set to be renewed
  every 90 days, with a notification time
  of 5 -7 days.
• You will receive e-mail notification in
  VISTA of patients whose flags are due
  for review.

                                        47
                           Renewing the flag:




This action is taken in Vista, using the Record Flag Assignment that
was used to set the flag initially.




                                                                       48
49
You can renew the flag,
inactivate the flag, or correct
a flag set in error.


                                  50
             FEE BASIS CONSULTS

• Provider enters consult to Fee Basis
• Alert generated to WVPM and
  designated alternate
  – Mechanism for establishing the record
    flag
• Capability for Interfacility electronic
  consults (VISN 8)



                                            51
Reason for request




                     52
53
Women‟s Health staff are responsible for the setting, reviewing,
editing and removal of these record flags in a timely manner.
If you have any questions about using the software, please contact
the Clinical Application Coordinators at your site.




                                                                     54
HPV Clinical Reminder
             Background
• In June 2006, the FDA approved the
 first vaccine for prevention of cervical
   cancer and genital warts. Over 200
  women veterans at the Tampa VAMC
met age criteria for CDC guidelines for
             HPV vaccination.




                                        56
                          Why is HPV Important?
              A Virus our Women Veterans Needed to Know About


                    HPV = Human Papilloma Virus

•   Genital human papilloma virus is common in the United States.
•   20 million people in the U.S. are infected with HPV
•   (1 in 4 women, ages 15-59)
•   Infections don't cause any symptoms and go away on their own.
•   HPV can cause genital and upper respiratory warts
•   There is no treatment for HPV infection.
•   HPV is important because it can cause CERVICAL CANCER.

                           Cervical Cancer

•   10,000 women get cervical cancer every year in the U.S.
•   3,700 die from it every year in the U.S.
•   2nd leading cause of cancer deaths among women around the world.



                                                                    57
                       Where do you start?
               Guidelines – Developed by Infectious Disease,
                          Gynecology, Pharmacy



                                Implementation Team
                            Gynecology, Primary Care,
                            Women's Health, Nursing,
                              Clinical Informatics,
                                       Pharmacy


Patient eligible for   Identify Patient Care Processes    Patient eligible for
 HPV: Reminder                  a. Contraindications      HPV: Physician
   comes due                                              provides
                           b.    Time of administration   education and
 Nurse provides
                                c. Special situations     enters orders
   education
                                   d. Availability
                Clinical Reminder Logic

Patient Cohort Logic:
• Due once for all women ages 11-26
• Not due if this health factor is on file in VistA:
   HPV VACCINE CONTRAINDICATED-ALLERGY
• Reminder Resolved by one of the
  following:
• Immunization finding: PAPILLOMA VIRUS
• Drug finding: HUMAN PAPILLOMAVIRUS VACCINE
  (Gardasil)
• CPT Code: HPV (PAPILLOMA VIRUS) VACCINE
• Health factor: REFUSED PAPILLOMA VIRUS VACCINE
  (for one year)
• Health factor: HPV VACCINE DEFERRED (for 6
  months)                                              59
                     Clinical Reminders

   Goal: To identify candidates for HPV at the time of
                   the primary care clinic visit.




Clinical reminders for “Consider HPV Vaccination” and “HPV Education” display
                           on the CPRS Cover Sheet
 Reminder Dialogs standardize progress note entry and collection of patient
              education and/or immunization data elements

                                                                          60
Consider HPV




               61
62
63
HPV Education




                64
                               Order Set
Orders to schedule appt, consult to Nursing Intervention, follow up
Beta HCG lab tests, and Medication Order




                                                                      65
Presenter: Cheryl Knowles RN, MSN, HNC

•   Master of Science in Nursing, Registered Nurse

•   National certified holistic nurse (HNC) - demonstrates competency
    and expertise with integrating holistic approaches into nursing
    practice

•   Lead Women Veterans Program Manager at VA Healthcare Network
    Upstate New York (VISN 2)

•   Women Veterans Program Manager VA Healthcare Network Upstate
    New York at Bath and Canandaigua

•   Specializing in women’s health since 1995

•   Federally employed for 26 years in Nursing; 34 years total
    experience in field of nursing

                                                                        66
          Mammograms and Pap Smears

• CPRS GUI interfaces with the Women’s
  Health (WH) VistA software package (2005)

• Provides reminder dialogs that update WH
  package at the same time that clinical care is
  recorded in CPRS GUI, thus eliminating the
  need for dual data entry

• Produces a signed progress note that
  documents Pap Smear and mammogram
  procedures, and WH patient notifications


                                               67
                       Closing the Loop


New computed findings resolve Mammogram and Pap
  smear screening reminders when procedures are:

  – Recorded in VistA Radiology package
  – Automatically uploaded into WH from the VistA Radiology
    package
  – Manually entered into WH

  – Recorded in VistA Lab package
  – Automatically uploaded into WH from the VistA Lab
    package
  – Manually entered into WH


                                                              68
                       2005 Changes

• Every site should have installed the screening
  reminders because they replaced the old cervical
  cancer and breast cancer screening reminders
  (2005)

• Every site should have at least installed and
  configured the Women’s Health package so the PAP
  smear screening reminder works

• Screening reminders designed to work for all sites,
  whether they use the WH package or not



                                                        69
          For Review reminders to work:

• Your site must have procedures
  entered & verified in VistA Radiology
  and/or Lab packages
  – Set up a default Case Manager
  – Map SNOMED codes from VistA Lab to
    WH
  – Identify/Create quick orders and map
    them to mammogram and PAP smear
    reminder dialog elements
  – Map radiology procedures to mammogram
    screening reminder
                                          70
               Set Ups Needed:

• Reminders package
  – Determine if your site will use Print Now
    functionality


• Women’s Health package
  – Customize default copy of WH letter with address
    data
  – Customize text of each WH result & reminder
    letter
  – Set up WH site parameters
  – Do not set up WH diagnosis translations

                                                   71
   Mammogram and Pap Smear
Coversheet - Screening Reminders




                                   72
PAP Smear Screening and Frequency




                                73
Mammogram Screening & Frequency




                              74
Mammogram and Pap Smear Results
      Review Reminders




                             75
Pap Smear Review Results




                           76
Procedure Report within Reminder




                              77
Clinical Review & Pt
     Notification




                       78
Mammogram Review Results




                       79
80
Sample Letter Notification




                             81
Review Reminder – Not Due




                            82
                    Notification Letters

• If your site plans to send WH letters, you will need
  to customize each result letter before you begin to
  use the review reminders

• Before you customize individual letters in the WV
  NOTIFICATION PURPOSE file, someone should edit
  the default letter format in the WV LETTTER file
  using FileMan

• The Integration with Women’s Health setup guide
  tells you how to use notification functionality and
  alerts even if you do not plan to actively use the WH
  package


                                                         83
                      References

• CPRS: Integration with Women’s Health
  Installation & Setup Guide during installation
  and setup of WH software
• Power Point 2005 titled “CPRS Integration
  with The Women Veterans Health Program”

  – Pre-Install Worksheet helpful – lists quick
    orders and Radiology procedures you will
    be prompted for during installation


                                               84
             Entering Outside VA
          Mammogram Reports into CPRS

• Outside report is faxed to a centralized
  location in clinical health area (WVPM)

• Report is directly scanned into the
  EMR and attached to the consult
  progress note

• Ordering/primary provider is added as
  an additional signer to the scanned
  note                                  85
               Provider and Clerk
                 Responsibilities

• Ordering/primary provider reviews the
  scanned mammogram report, initiates
  an addendum to the same note with
  completing the mammogram review
  clinical reminder, signs note
• Clerk prints reminder and/or
  notification letters and mails to pt



                                      86
   Loop starts Here:                 Mammogram is
   Patient reports                   performed at a             Mammogram is
   for mammogram                     community site             read and
   testing                                                      verified by the
                                                                NonVA
                                                                Radiologist
                                     FLOWCHART
WH Staff in Primary Care                                        Report is faxed
Team (Nurse/Clerk) print and                                    to a centralized
mail letter or call. pt to follow-                              location at VA
up with patient notification                                    facility
Loop is Closed:

                                                      Report is scanned
     Alert sent to Provider and WH Staff              into EMR and
     Both sign note with Provider                     attached to
     completing Mammogram Review                      consult note with
     Clinical Reminder                                Provider and WH
                                                      Staff as additional
                                                      signers
               Osteoporosis

• Silent, progressive, debilitating disease

• Robs bones of mass, results in
  weakened bones, creates high risk of
  fractures

• Preventable and treatable

• Under-recognized and under-treated
                                          88
              Bone Density Screening

• Dual-energy x-ray absorptiometry
  (DXA) - Gold standard in measuring
  bone mineral density (BMD)

• 80% of those affected by osteoporosis
  are women *(NOF 2007
 www.nof.org/osteoporosis)


• Due once in a lifetime for women 60
  years and older.
                                        89
           Clinical Reminder Resolution:



• Cover Sheet of Patients record in
  CPRS lists “due” clinical reminders

• Bone Density Screen       DUE NOW
  will be shown on cover of record

• Select new note, then reminders
  drawer to find and click on “Bone
  Density Screen”
                                           90
                Overall dialog:
After clicking on “Order Bone Density Screening Tests” then
        Clicking on “FINISH” presents an order menu.




                                                          91
        Historical Entry
Enter results, date, location, screening method.




                                                   92
                 Options
    Patient can refuse: resolves for 1 month
Life Expectancy <6 months : turns off reminders




                                                  93
                    Screening Interval
 Can change screening interval; set up to reappear according to selection
checked. If nothing is checked, screening will default to once in a lifetime.




                                                                          94
            Further CPRS Capabilities

• Local templates, quick order, and consults
  for gender specific care, such as GYN,
  Breast Care Management, etc. can be
  created and mapped to applications such as
  clinical reminders

• Recommendations are to work closely with
  content experts, such as the Women
  Veterans Program Manager, Clinical
  Applications Coordinator, Compliance
  Officer, HIMS staff, Coders, and Women’s
  Health Care Providers                        95
Questions?




             96

				
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