Valentin O. Rivish, RN, BSN, MSN
and Manolo D. Moneda, RN, BSN, MBA
This article was made possible by an educational grant from
Chamberlain College of Nursing
Rivish, V. and Moneda, M. (October 2011). Obtaining Remote Data Using the Veteran’s Affairs Computerized Patient Records System. Online Journal of Nursing Informatics (OJNI), 15, (3). Available at http://ojni.org/issues/?p=905
Patients often see multiple providers within various healthcare systems. A provider’s ability to access a patient’s chart from another system is critical to saving time and money, as well as providing quality care. The Remote Data capability of the Computerized Patient Record System (CPRS) used at the Department of Veterans Affairs allows providers to do just that. This article explains this efficient exchange of information and offers actual screen shots from CPRS illustrating what a provider would see.
On March 4, 1865, as the nation braced itself for the final effects of the Civil War, thousands of people gathered to hear the famous words of President Lincoln’s second inaugural address. It was in this speech that President Lincoln affirmed the United States government’s obligation to care for those injured during the war and to provide for the families of those who died on the battlefield (United States Department of Veterans Affairs, 2009a). By serving and honoring America’s veterans, it has become the mission of the Department of Veterans Affairs (VA) “to fulfill President Lincoln’s promise ‘To care for him who shall have borne the battle, and for his widow, and his orphan’” (United States Department of Veterans Affairs, 2009b, ¶ 1). The VA’s vision is “to provide veterans the world-class benefits and services they have earned – and to do so by adhering to the highest standards of compassion, commitment, excellence, professionalism, integrity, accountability, and stewardship” (United States Department of Veterans Affairs, 2009b, ¶ 2). So how is it that this nation’s largest integrated healthcare system is able to support and stand behind such a sovereign mission and vision, and why is the VA recognized for its leadership in clinical informatics? The answer to these questions lies in the most broadly implemented and highly functioning health information technology system in the world. The VA uses a system known as Computerized Patient Record System (CPRS), which allows clinicians to do what other healthcare systems only dream of. A recent seminar presented by the VA Information Resource Center (United States Department of Veteran Affairs VA Information Resource Center, 2011), reported that most VA staff love CPRS due to the accessibility and accuracy of patients’ records, as well as the ease of viewing and sharing information. This article offers a closer look at the remote data functionality of the CPRS system and its benefits.
It is documented that there are inefficiencies in the exchange of patient information within healthcare systems and poor data liquidity between care providers (Center for Information Technology Leadership, 2008). According to two Center for Disease Control reports, patient information is often retained in various systems because patients have an average of four outpatient visits annually with different healthcare providers (Cherry, Woodwell, Rechtsteiner, 2005; Middleton, Hing, Xu, 2005). The efficient exchange of this information is critical to enhanced quality of care and cost containment (Pan, et al. 2005). Burton, Anderson, and Kues (2004), report that having a way to facilitate the exchange of clinical information among healthcare providers would greatly enhance the care coordination of millions of patients with multiple chronic illnesses. CPRS is implemented at all VA medical centers nationwide. With a few clicks of the keyboard, CPRS’s Remote Data allows clinicians to access medical records from any VA medical center or outpatient clinic in the country in which patients have been seen.
Because veterans often seek care at multiple VA sites, it is important for clinicians to have the ability to retrieve data from any other VA facility where the veteran has been seen. This capability prevents duplication of exams and tests that have already been completed, thereby saving money and time. Universal access to records also eliminates the time-consuming problem of transferring paper records from one location to another, and it gives the clinician the needed information at the time of the patient’s visit.
When a clinician opens a patient record with CPRS and requests Remote Data views, CPRS queries the master patient index to obtain a list of remote locations where the veteran has been seen. If a clinician chooses the All Available Sites option, CPRS will display the data that the clinician needs to view from all of the sites that the patient has previously sought care. Figure 1 is a screen capture from CPRS that shows the view that a clinician from the Phoenix Veterans Affairs Healthcare System (PVAHCS) in Phoenix, Arizona would see while retrieving Remote Data. Specifically, this view shows a progress note titled “Surgery Nursing Procedure Report” on a patient who had surgical intervention at the Northern Arizona Healthcare System in Prescott, Arizona. The clinician in Phoenix is now able to read progress notes that were entered on this patient by a clinician at a different VA hospital. On the left-side column, the clinician can select the type of report for a specific date range. The available report types include dietetics, discharge summaries, laboratory, medicine, orders, outpatient encounters, pharmacy, problem lists, progress notes, radiology, and more.
CPRS view in Phoenix, Arizona, of Progress Note written in Prescott, Arizona.
Figure 2 is a screen capture that shows how a care provider’s view looks in CPRS at the PVAHCS in Phoenix, Arizona accessing lab results that have been done at the NAHCS in Prescott, Arizona. Using CPRS, all that the care provider has to do is first select the type of report on the left, then choose the date range that he/she wants to view. Then all of the requested information becomes available on the screen, enabling him/her to make the clinical decisions necessary for the patient.
CPRS view in Phoenix, Arizona, of lab results done Prescott, Arizona.
The process of obtaining progress notes or other information such as laboratory data, physician’s orders, advanced directives, vital signs, surgery reports, etc., is very cumbersome and time consuming without having the benefits of the technological advances of systems like CPRS. The provider has to question the patient to find out where the patient has previously sought care. Then, the provider must request consent from the patient, having the patient sign a paper consent form stating that the patient agrees to have the requested information released to the requesting healthcare organization. The consent is then faxed. After the fax is received, the requested information is located and obtained from the medical records or health information management system (HIMS) department of the requested hospital. Once the requested information is located by medical records or HIMS, it then needs to be faxed to the requesting facility where the patient is currently seeking care. This process, depending on variables like dates of previous visit, staffing and hours of operation in medical records or HIMS, access to old medical records, fax machine functionality, etc., can potentially take up to several days. This delay can result in extended lengths of stay, increased costs accrued from unnecessarily repeating laboratory and other diagnostic exams, delays in care delivery, and frustration to care providers and patients alike. Within the VA, obtaining consent to gather information from one facility to another is not necessary because the information is not leaving one healthcare system and going to another; it all stays in the VA system.
Figure 3 illustrates how a care provider in Phoenix, Arizona can view an informed consent that was documented in Prescott, Arizona for a colonoscopy.
Other Remote Data Views Available in CPRS
In order to respect the capabilities of Remote Data views, an understanding of how the Master Patient Index (MPI) works and how it can manage person identification and cross-reference across different systems is required. The Master Patient Index (MPI) is found at the Austin Information Technology Center (AITC). It is a collection of a unique list of patients and an associated list of VAMCs (Veterans Affairs Medical Centers) as well as other systems of interest each patient has visited. This enables the sharing of patient data between operationally diverse systems. Each patient record on the MPI has multiple demographic fields that are updated to the Primary View of the MPI (United States Department of Veterans Affairs, 2010a). An MPI can be called a correlation manager for various data processing needs, from laboratory to billing, each with its own database of people and person identifier numbering schemes.
Administrative staffs are responsible for entering patient data into individualized patient files into Vista, which will eventually populate CPRS. Catastrophic edits can occur whenever there is a human element in entering data. Catastrophic edits cause a change in a patient’s identity or health record. Catastrophic edits are a result of changing the key demographic traits (e.g. first name, last name, SSN, date of birth, gender), either in error, by choosing an erroneous patient, or intentionally “re-using” entries in the PATIENT file. This causes the alteration of patient identity, and consequently, patient care can be adversely effected (United States Department of Veterans Affairs, 2010b). Prior to implementing MPI, nearly 1% of the records on the MPI are duplicates. While seemingly insignificant, with more than 15 million patients being on VHA’s MPI, it can cause noteworthy workload due to time needed for record review and resolution. The only way to handle the on-going emergence of duplicate records is with dedicated man-hours (United States Department of Veterans Affairs. 2010a). According to the enrollment training initiative, the Administrative Data Quality Counsel developed a number of training goals in order to eliminate the occurrence of catastrophic edits. The goals are: eliminate catastrophic edits; define a catastrophic edit and its impact on patient care and patient safety; identify VA-wide implications; learn how to report and correct errors; and certify all responsible VA staff members and supervisors (United States Department of Veterans Affairs, 2010a). With the MPI’s capacity to uniquely differentiate patients who have had visits to multiple facilities and to provide a list of all facilities at which a patient receives care, the opportunity exists for other applications to be utilized. As VHA embarks on the reality of having one electronic record for one patient and being able to share that record among stakeholders, it is crucial that each patient’s unique record identity is maintained and that duplicate patient records are eliminated (United States Department of Veterans Affairs, 2009c).
In CPRS, there is an additional functionality (see Figure 4) that warrants mentioning, which serves as a backup to Remote Data.
VistaWeb Option in CPRS
VistaWeb is an intranet web-based application that provides the user with the same information in Remote Data, but in a web-based format. VistaWeb was developed by VA programmers. In 2005, VistaWeb became nationally supported and released for use by the entire VA system (United States Department of VA, 2009d). Should internet capability cease to function or be temporarily out of order, Remote Data remains available to CPRS users. Figure 5 is an example of a VistaWeb screen (Healthcare Information and Management Systems Society, 2011).
VistaWeb Screen Shot
The Remote Data available in CPRS are one of many technological advances that aides the VA in providing this country’s veterans the world-class services they have earned. In fact, the VA was named one of the recipients of the prestigious Innovations in American Government Award presented by the Ash Institute of the John F. Kennedy School of Government at Harvard University (United States Department of Veterans Affairs, 2006). This award tells America what millions of veterans and their families have known for years – that the VA delivers superlative health care in a professional, compassionate and high-tech environment. The VA uses modern technology to digitize and streamline health records, causing American veterans to be the recipients of the most premium health care in the nation. The VA has considerably improved efficiency, discernibly improved clinical decision making, and reduced costs (Harvard Kennedy School ASH Center for Democratic Governance and Innovation, 2011).
Remote data views are one element of an advanced electronic health record, CPRS. That is a source of pride for staff and veterans alike. Staff and patients of the VA are highly satisfied with the technological capabilities that CPRS provide. The Remote Data views capability in CPRS provides access to vital healthcare information for patients that have sought care at other VA facilities. Being able to electronically obtain and view progress notes and other information such as laboratory data, physician’s orders, advanced directives, vital signs, surgery reports, etc., is a valuable tool in today’s electronic record technology.
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Valentin O. Rivish, RN, BSN, MSN
Mr. Rivish is currently a Nurse Manager at the Phoenix Veterans Affairs Health Care System (PVAHCS), and an Adjunct Faculty for the Nursing Division at the GateWay Community College. His previous positions at the PVAHCS include Nursing Supervisor (house supervisor), Clinical Applications Coordinator (CAC), Tele-Health Care Coordinator, Inpatient Case Manager, and Intensive Care Unit Nurse. As a CAC, he taught hospital-wide employees (RNs, LPNs, NAs, physicians, interns, residents, and others) how to use the VA’s Computerized Patient Record System (CPRS) and Bar Code Medication Administration (BCMA) software. He served as the medical center Bar Code Expansion Coordinator. He has had the privilege to build, test, and put into practice all of the Inpatient and Outpatient MRI order sets and order templates.
Manolo D. Moneda, RN, BSN, MBA
Manny is currently working as the Nurse Manager for the Specialty clinics at the Phoenix Veterans Affairs Health Care System (PVAHCS). He also holds an Adjunct Faculty position in the Nursing Division at GateWay Community College as well as Adjunct Faculty for the Business Division at GateWay Community College involved with the Health Information Technology Grant. He is retired after serving 27 years in the U.S. Air Force Reserves and Active Duty. Manny’s previous positions at the PVAHCS include being the Nurse Manager of the Emergency Department, Clinical Applications Coordinator (CAC) for eight years, Nursing Supervisor, and Medical/Surgical Nurse. As a CAC, he implemented the roll-out of the Bar Code Medication Administration software at the VA. He was also instrumental in the development of standards of practice order sets in the Computerized Patient Record System (CPRS) at the VA.