1. EPMO Open Source Coordination Office Redaction File Detail Report

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#	Location	File	Last Modified
1	CPRS_Enh_P1.zip\09 20130504 - Address notification software problem seen when an ordering provider changes role	Minutes to the Follow-Up Discovery Meeting_NSR20130504 _4_14_2017.doc	Tue Nov 14 18:19:26 2017 UTC
2	CPRS_Enh_P1.zip\09 20130504 - Address notification software problem seen when an ordering provider changes role	Minutes to the Follow-Up Discovery Meeting_NSR20130504 _4_14_2017.doc	Thu Nov 16 13:58:38 2017 UTC

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	1	Minutes to the Follo w – Up Dis covery Mee ting
	2	EP1
	3	NSR 201305 04 - ADDRE SS NOTIFIC ATION SOFT WARE PROBL EM SEEN WH EN AN ORDE RING PROVI DER CHANGE S ROLE
	4	Meeting Na me: Addre ss Notific ation Soft ware Probl em Seen Wh en an Orde ring Provi der Change s Role
	5	NSR: 2013 0504Analys t: Susan Scorzato
	6	Scribe: B lair Sande rsManager: Craig H inton, Sha wn Suiters Date: Apri l 14, 2017 Time: 1 P M Pacific ; 2 PM Mou ntain; 3 P M Central ; 4 PM Eas ternLocati on: 1-844 -358-7954
	7	Passcode: 750445462L ast Name
	8	First Name
	9	Organizati on/Role
	10	Attendance
	11	Kroupa M.D .
	12	Laura
	13	Network Me dical Info rmatics Of ficer, VIS N 15
	14	X
	15	Volpp M.D .
	16	Bryan
	17	Physician, VISN 21 I nformatics , VHA
	18	Davoren M. D.
	19	Ben
	20	ACOS, Clin ical Infor matics, Ch ief of Sta ff
	21	Faustina
	22	Mary Lou
	23	Clinical A pplication Coordinat or, Chief of Staff
	24	Cho
	25	Richard
	26	Clinical A pplication Coordinat or, VA
	27	X
	28	McFarland
	29	Sean
	30	Clinical A pplication s Coordina tor (RN), OIT
	31	X
	32	Finley
	33	Scott
	34	Physician Informatic ist, VHA/O IA/HI/Heal th System Informatic s
	35	X
	36	Acker
	37	Beth
	38	HIM Specia list, Heal th Informa tion Manag ement
	39	X
	40	Heller
	41	Pam
	42	Director, HIM, Healt h Informat ion Manage ment
	43	Weems
	44	Shelley
	45	Health Inf ormation S pecialist, Health In formation Management
	46	Teal
	47	Jennifer
	48	HIM Specia list, Heal th Informa tion Manag ement
	49	Gleave
	50	Denise
	51	Program An alyst, VHA
	52	Yahnian
	53	Jennifer
	54	Pharmacy I nformation Manager/A DPAC, VHA
	55	X
	56	Powles
	57	Patricia
	58	HIMS SPECI ALIST, VHA - Health Informatio n Manageme nt
	59	Pettis
	60	Jerry
	61	Computer S pecialist , VHA
	62	X
	63	Stephenson
	64	Scott
	65	HP Delphi / Mumps De veloper
	66	X
	67	Davis
	68	Robert
	69	HP Delphi / Mumps De veloper
	70	X
	71	Suiters
	72	Shawn
	73	HP Project Manager , VA
	74	X
	75	Hinton
	76	Craig
	77	HP Project Manager , VA
	78	X
	79	Crumley
	80	Jamie
	81	HP Delphi / Mumps De veloper
	82	X
	83	Swesky
	84	Jeff
	85	HP Delphi / Mumps De veloper
	86	X
	87	Stephenson
	88	Scott
	89	HP Delphi / Mumps De veloper
	90	X
	91	Andriyevsk iy
	92	Andrey
	93	HP Delphi / Mumps De veloper
	94	Watts
	95	Brian
	96	HP SQA Ana lyst
	97	Scorzato
	98	Susan
	99	HP Functio nal Analys t
	100	X
	101	Sanders
	102	Blair
	103	HP Technic al Writer
	104	BN 1: U sers invol ved in the alerts/no tification s manageme nt process need the ability to ensure th at patient -related n otificatio ns are sen t to the c orrect pro vider, so that patie nt care is not delay ed.
	105	When provi ders assu me a new r ole or dut ies, need the abili ty in a si ngle actio n to assoc iate one, many, or a ll of my s igned orde rs (as wel l as actio ns resulti ng from th ose orders ) to the n ew assigne d provider (s), so th at all sig ned order notificati ons are au tomaticall y sent to the new re sponsible provider(s ).
	106	Providers assuming a new role or duties within or outside o f VA need their info rmation to remain as sociated w ith their signed ord ers along with the n ewly assig ned provid er(s)' inf ormation, so that th e audit hi story and integrity of the med ical recor d is readi ly accessi ble.
	107	Providers assigned r esponsibil ity for th e patients of a prov ider who a ssumes a n ew role or duties ne ed to be i nformed of that assi gnment, so that they can verif y and acce pt or not accept tha t they are the corre ct provide r for the signed ord er(s) and resulting actions.
	108	Susan Scor zato: Thos e are the three requ irements t hat we do have.
	109	Scott Finl ey: Could I ask two scope ques tions?
	110	Susan Scor zato: Abso lutely.
	111	Scott Finl ey: First scope ques tion is it appears f rom what y ou have sa id that yo u are limi ting the s cope to pe rmanent ha ndoffs rat her than t o temporar y handoffs . I’m not sure that is true. I t just see ms to be i mplied so I am askin g if that is how you are think ing about this.
	112	Jamie Crum ley: So ca n I say so mething ab out this S usan?
	113	Susan Scor zato: Yes
	114	Jamie Crum ley: Nobod y ever men tioned a d ifference between pe rmanent an d temporar y handoffs . Could yo u talk to us about t hat?
	115	Scott Finl ey: Sure. Imagine a provider i s going to be gone f or six wee ks for som e major su rgery. Or imagine a provider i s taking t wo weeks o ff and nee ds appropr iate notif ications c overing hi s or her p atients wh ile away. Those are examples o f temporar y handoffs . A very t emporary h andoff wou ld be who is coverin g for toni ght. You h ave a diff erent leve l of need for shorte r handoffs . Characte ristic of them is th at they ar e easily r eversed be cause you expect the m to be re versed.
	116	Jamie Crum ley: Okay then I thi nk that we would exp ect they w ould handl e that wit h surrogat e users. I n that res pect, I se e exactly what you a re talking about. In that resp ect, yes t his NSR is talking a bout a per manent rea ssignment of that pa tient.
	117	Scott Finl ey: Okay s o that lea ds to my s econd scop e question . I recomm end that w e make thi s explicit . Whether I am delig hted that we are han dling them completel y differen tly, I don ’t know bu t it shoul d at least be really clear tha t we are. There is a n implied requiremen t that you could eas ily not me et if you don’t arti culate it which is y ou may hav e to do th is more th an once. S ometimes p atients ha ve very lo ng hospita l stays fo r example, and multi ple people may rotat e off serv ice during the cours e of it.
	118	Jamie Crum ley: Yes t hat is abs olutely tr ue and one of the th ings that we talked about last time is t hat the ta sk of doin g somethin g that is auditable and mainta ins every single one of these changes. S o that was anticipat ed yes.
	119	Scott Finl ey: Okay! Great! Tha nks. Those were my t wo questio ns about s cope.
	120	Susan Scor zato: Okay . Thank yo u Scott an d Jamie. T his is the GUI proto type suppo rting the reassignme nt of pati ents from one provid er to anot her. We wi ll get int o the mock up after w e address our questi ons.
	121	Below you will find the GUI pr ototype su pporting t he reassig nment of p atients fr om one pro vider to a nother:
	122
	123	Susan Scor zato: Star ting with some of th e question s here. Do you mind if we just jump into these que stions? (n o response ). Okay. T he first q uestion is :
	124	QUESTIONS:
	125	When reass igning new patients, will ther e be one p atient alw ays assign ed to one new provid er or can one patien t be assig ned to mul tiple new providers i.e. speci alist? (Ou r assumpti on is that when you are reassi gning thes e patients , you are reassignin g these or ders that provider w rote for t hat partic ular patie nt and not touching the patien t’s other orders.)
	126	Susan Scor zato: Any comments?
	127	Scott Finl ey: I thin k there is a tension between c ontrol and usability implied. That is to say you c an probabl y imagine a scenario in which it would b e nice to manage the orders in dividually . But what a pain in the neck. So I am g oing to gu ess that t he correct minimum g ranularity would be the patien t level. B ut I am op en to hear other opi nions.
	128	Laura Krou pa: I woul d think th at most of the time we would b e wanting to reassig n patients . We have some funct ionality i n CPRS to when we wr ite an ord er to aler t someone else to th e results of that or der if we want to. I don’t thi nk it is d one very o ften becau se it is s o difficul t and so g ranular. B ut we do h ave that. Once the o rder’s bee n written, the abili ty is lost . But I wo uld think that there is not ve ry many ti mes you wo uld want t o send one result on a patient to one pe rson and a different alert to a differen t person. It would b e very cum bersome to try to do that for a lot of p atients. I t would be almost im possible.
	129	Scott Finl ey: The co ntext here is I am p ermanently in essenc e going of f service. Presumabl y I have a whole mes s of order s to hand off.
	130	Laura Krou pa: Right, right.
	131	Jamie Crum ley: To ki nd of furt her that t heory on I guess our thinking is that yo u’re rotat ing a prov ider off. You are no t rotating every pro vider that has ever written an order for that pati ent.
	132	Scott Finl ey: I wasn ’t suggest ing otherw ise. For t hat provid er, the tr ick is to take the p erspective of the us er. The u ser’s pers pective is every ord er that he or she ha s written that has s ome status for which is releva nt and nee ds to be h andled by somebody e lse going forward.
	133	Jamie Crum ley: Right . Exactly
	134	Scott Finl ey: So dea ling with them on an order by order basi s is impra ctical.
	135	Jamie Crum ley: That’ s how come when you see the mo ckup demo, you’ll no tice what you are pi cking is a patient n ot an orde r but the thing we n eed to all remember is that it is not go ing to cha nge every single ord er for tha t patient, but the o ne that th at particu lar provid er wrote. We just wa nted to be clear on that.
	136	Sean McFar land: This is Sean. Just to cl arify, doe s it keep intact the original ordering p rovider an d essentia lly reassi gn the res ults to an other pers on?
	137	Jamie Crum ley: Well, we can’t redo the e ntire aler t notifica tion syste m which we would hav e to do in order to create a b rand new t hing basic ally. So w hat we sor t of agree d with in the last c onversatio n we had i s we will change the fields ne cessary th at the ale rt notific ations are looking f or but the change wi ll be audi ted and be available in Order Details an d on the e lectronic chart. The refore, it will be a vailable i n the hist ory of tha t patient for the el ectronic m edical rec ord for ev ery time t hat change occurred because it might hap pen as we said more than once.
	138	Sean McFar land: I do remember that conve rsation. T hanks for clarifying it.
	139	Jamie Crum ley: As fo r your que stion Beth , that is one of the things th at We are going to t alk about that later . I think unassigned orders ha ve to be c onsidered basically because yo u do not w ant the un signed ord er to sit out there and langui sh if this provider has moved to another service. But we did want to t alk to you about wha t types of orders. I n fact, I think that is about to come up and what status of orders are . Our assu mption is if an orde r is disco ntinued, e xpired, or cancelled , that we don’t nece ssarily ha ve to move that orde r because that could be a trem endous amo unt of ove rhead. Bas ically we are trying to look f or orders where no n ew activit y is expec ted. Unles s of cours e somebody copied th at, it wou ld create a new orde r. We were getting t o that in a moment.
	140	Sean McFar land: Jami e in terms of the fi rst questi on so woul d the sett ing be onl y one pati ent at a t ime or cou ld it be a n all pati ent panel?
	141	Jamie Crum ley: You’l l see In a minute th e demo and what we h ad in mind . Basicall y would be you put i n a provid er and it pops up ev ery patien t that hav e orders t hat meet t he criteri a that we decide on. They can reassign t hem to one or other providers. I think i t will be a little b it clearer when you see the mo ckup act.
	142	Susan Scor zato: Once I pull th e demo up, it will b ecome a li ttle clear er for you . We just kind of wa nted to go through s ome of the se questio ns. As Jam ie said, t he next qu estion we would like to addres s is the t ype of ord ers and wh at type of orders wo uld you li ke to be a ble to mov e.
	143	Are we rea ssigning p atients or patient o rders?
	144	Which type s of Order s would yo u like to be able to move?
	145	Imaging, C onsults, M eds, Labs, Clinic In fusions?
	146	Scott Finl ey: I’d tu rn the que stion arou nd and ask our there any that we shouldn ’t.
	147	Susan Scor zato: Okay , so you a re saying everything ? So would anybody w ant to com ment on th is?
	148	Jamie Crum ley: The r eason that we asked this is it seemed li ke last ti me the que stion of m edication orders was raised an d whether or not we should rea lly do som ething wit h those. I can’t rem ember the details un fortunatel y.
	149	Richard Ch o: Would M eds be a b it tricky in terms o f controll ed substan ce orders? For examp le, the cl inician or iginally h ad the abi lity to or der contro lled subst ances but for all pa tients can ’t enter a specific type.
	150	Jamie Crum ley: Right that is a n excellen t point. C ontrolled substances orders wo uld…
	151	Scott Finl ey: That’s a more sp ecific ins tance of t he more ge neral prob lem of sur rogate. I am going t o use the word surro gate even though it is mislead ing. We ha ven’t give n a name y et to the recipient of this ha ndoff. But in genera l, that pe rson might not have the privil eges to pl ace some o f the orde rs and to hand it of f to him o r her.
	152	Susan Scor zato: That ’s correct .
	153	Scott Finl ey: In fai rness, the y are also not placi ng the ord er. So rea lly the is sue is som ebody has got to own it. They got to own the downs tream impl ications o f that ord er like be ing alerte d to resul ts, being called by the pharma cist about a questio n about it , or a con cern about it. A who le bunch o f things t hat could happen to an order a nd somebod y with a p ulse that would be o n the rece iving end of those c ommunicati ons. I’m n ot sure th ey have to have the privilege to place t he order i n the firs t place. I hope they don’t or we could g et into tr ouble.
	154	Richard Ch o: Typical ly the rea ssignment is for in general a follow up, right? If somebody has a ques tion or if the resul ts come in so in ter ms of priv ileges tha t would de pend on wh at the fol low up is needed for . If a ren ewal came up for a m edication, they shou ld have th e ability to renew t hat medica tion. The privilege to just to renew tha t.
	155	Scott Finl ey: I am b asically a greeing. M y friendly amendment , Richard would be t hat, obvio usly the w orld works more smoo thly if th ey have th e privileg es to proc ess that r enewal. Bu t failing that if th ey are at least awar e that a r enewal nee ds to occu r, than pr esumably t hey are in a positio n to find someone wh o does hav e that per mission to process t hat renewa l. Am I ma king sense ?
	156	Richard Ch o: Right, completely . So then they would somehow f orward tha t alert. W hat kind o f alert is this? Wou ld all of these be a ctionable or would s ome of the m be infor mation onl y? I gues s that wou ld depend on the ori ginal, rig ht? I know some aler ts are inf ormation v ersus acti onable.
	157	Jamie Crum ley: They could be a nything be cause it’s whatever happens la ter basica lly.
	158	Richard Ch o: So if i t is an al ert that n eeds actio n and they process i t but they don’t hav e privileg es to do i t, does th at alert c ome back?
	159	Jamie Crum ley: Well, I think w e are goin g to have to do a di sclaimer t o whoever is doing t his reassi gnment. Th ey are res ponsible f or reassur ing whoeve r they are reassigni ng it to, has the ad equate pri vileges to do that. I wonder h ow we coul d tell if they have…
	160	Scott Finl ey: Oh you could tel l. It woul d be a pai n in the n eck. Essen tially you could che ck every o ne of thos e orders.
	161	Jamie Crum ley: Actua lly, what you could do is comp are the se tup of the two provi ders to se e if they have got t he same pr ivileges. It would a lso be a p ain in the neck.
	162	Scott Finl ey: You do n’t really require i dentical p rivileges you just n eed to req uire suffi cient priv ileges whi ch is a lo wer bar bu t harder t o test.
	163	Jamie Crum ley: Yes.
	164	Richard Ch o: I’m not sure if y ou have an other ques tion below but would it only b e the orde ring provi der who is allow to reassign?
	165	Jamie Crum ley: It wo uld not be the order ing provid er who doe s that. Th e patient at our las t meeting was a sect ion chief doing this . It could somebody that the s ection chi ef appoint s to do th is but it would most likely no t be the o rdering pr ovider tha t was doin g it. It i s not anti cipated th at it woul d necessar ily be the ordering provider.
	166	Scott Finl ey: You co uld imagin e a variet y of scena rios where somebody leaves wor k one day and un-exp ectantly n ever retur ns to work .
	167	Jamie Crum ley: Oh th at is a go od point.
	168	Richard Ch o: Was the re some ot her discus sion about connectio n or inter face with a pact whe re the pac t coordina tor change s the prim ary provid er of a pa nel and it is automa tically do ne.
	169	Laura Krou pa: If the re is a pr imary care provider the way a lot of ale rts are se t you are going to g et those r esults bec ause you a re not a p rimary car e provider depending on how yo ur site ha s those th ings set. If you hav e an alert set to go back to t he primary care prov ider once the primar y care pro vider is c hanged, th en you are going to get that a lert not b ecause you are the o rdering pr ovider but you are g oing to ge t it becau se you are the prima ry care pr ovider.
	170	Scott Finl ey: You’re saying th at will wo rk because it is rol e based, r ather than individua l based.
	171	Laura Krou pa: Exactl y. In prim ary care w e are actu ally prett y robust i n terms of getting p eople swit ched aroun d. It is o ther place s in the h ospital wh ere patien ts aren’t really ass igned to p eople in w ays they a re in pact . That is where we r un into is sues with this.
	172	Sean McFar land: I th ink you ar e referrin g to the p rovider/re cipients p arameter. If a parti cular noti fication i s set up t o go to th e PCP or t eam, the i ssuing pro vider know s how to c ontinue. H owever if it is only set up to go to the ordering provider, then that’ s where th is change would have to be mad e. I wonde r if facil itating th at change the orderi ng provide r could in the panel completel y change t o another PCP, would that be b uilt in to potential ly look fo r patients to make t hat change faster or easier.
	173	Jamie Crum ley: We ha d a really long disc ussion abo ut the car e team def inition la st time. T he bottom line was n obody felt comfortab le with th at definit ion becaus e we had o ne side on the call that menti oned that sometimes there upda tes are we eks behind or I thi nk one per son said t hat it was even a mo nth behind . Other pe ople said that their sites don ’t use it because of the delay s in updat es and tho se kind of things. O riginally that was o ne of the questions that we ha d in the f irst meeti ng was exa ctly that do you wan t us to ba se this on doing it automatica lly when t he care te am assignm ents are c hanged. Th e answer w as even it would be optimum if there was way to do it automa tically, t hey just d idn’t feel like the current in frastructu re would s upport tha t with the way their internal folks were working.
	174	Richard Ch o: So at s ome sites they don’t have the staff to s upport the timing ch ange of pr oviders an d they wou ld have to do it man ually. The y can’t re ly on the automatic.
	175	Jamie Crum ley: The o ther thing that they pointed o ut was one of their primary pu rposes of this was r otating re sidence at teaching facilities where the y are not necessaril y on the c are team i n a positi on like pr imary or a ttending o r anything of that n ature. Ess entially t hey are wo rking as s pecialty a nd they ar e just pla cing order s for thei r specialt y and ther efore they are on th e care tea m definiti on that wa s PCM anyw ay. They s aid that i t wouldn’t even work for them because of that situ ation as w ell.
	176	Richard Ch o: I under stand the need for i t outside of the car e team. I think that is much n eeded. We had a situ ation wher e a primar y care phy sician lef t from a C DOC. They of course made all t he changes within pa ct. But th en they ha d all thes e orders t hat they e ntered and for us we don’t hav e that pro vider/reci pient defa ult to pri mary care we have it for the o rdering pr ovider. In that situ ation, I g uess we wo uld have t o use this new tool and manual ly say for this prov ider as an ordering provider r eassign it to someon e. It woul d not be a utomatic.
	177	Jamie Crum ley: In th at particu lar instan ce, I supp ose you co uld automa te it off of primary care prov ider chang ing to new team but it would b e sort of sketchy in some situ ations to do it for that. When we did br ing up the PCMM team , the resp onse was r esoundingl y we would really ra ther you d idn’t do t hat.
	178	Sean McFar land: Jami e, I do re member tha t conversa tion of th e timeline ss of the assignment for that. One thing I was jus t thinking of is if every pati ent was re assigned f rom one pr ovider to another pr ovider, we concurren tly use a surrogate and they w ould just get all th e alerts f or that pe rson. The problem th at we have had and t he challen ge we have had here is when th e panels g et split u p and ther e is no re al one sur rogate tha t can be a ssigned.
	179	Jamie Crum ley: Well true and t hat is one of the ch allenges w ith doing it automat ically as well. Some times you don’t want it to go a one to o ne sort of exchange. The perso n may have rotated t o another service an d is alrea dy writing orders fo r new pati ents in th e new serv ice. That’ s why it l eads our p roposal if you guys approve it is we onl y bring up the patie nt that ha ve orders written by that pers on. It wil l get weir d if some reason the y move fro m one serv ice to ano ther and t hey are se rvicing th e same pat ient. We d on’t reall y have a g ood way to deal with that yet. Like if i t just so happens th e provider wrote an order for John Smith today on Service A and tomorr ow wrote i t on Servi ce B and y ou want th e Service A order to be reassi gned to so mebody els e. That is a little bit tricki er.
	180	Scott Finl ey: The on e partitio ning to at least tuc k away as possibly n ecessary w ould be in patient ve rses outpa tient orde rs. That is to say if a patie nt is curr ently hosp italized, you might not want t o reassign their inp atient ord ers to the same pers on as thei r outpatie nt orders.
	181	Jamie Crum ley: Would you expec t them to have inpat ient order s and outp atient ord ers writte n on the e xact same … So you’r e saying e ven on the clinic or der for a future app ointment o r somethin g.
	182	Scott Finl ey: So I c onfess to not knowin g exactly what we do with thei r outpatie nt orders whether we disappear them or s uspend the m when the y are admi tted. Do w e start al l over aga in?
	183	Jamie Crum ley: It de pends on t he service . It depen ds on how a particul ar site ha s defined their auto receive r ules.
	184	Scott Finl ey: All I mean is if orders ar e getting reactivate d, they wo uld someti mes want t o get reas signed to a differen t human th an the inp atient ord ers.
	185	Susan Scor zato: Well our next question t hat we do have is as follows:
	186	Which stat uses do we consider available for reassi gning?
	187	Hold, Flag ged, Pendi ng, Active Partial R esults, De layed, Unr eleased?
	188	Jamie Crum ley: Well hang on a second. Di d we get a n answer t o the ques tion which type of o rders and are there orders we would like to exclud e?
	189	Susan Scor zato: Well not a com plete answ er.
	190	Scott Finl ey: You go t an answe r in the s ense that nobody has suggested any for e xclusion. That’s why I suggest ed reframi ng it. May be complet ed orders and that s ort of thi ng. If any body can t hink of an y to exclu de but I j ust can’t think of a ny. The de eper quest ion is do these have to be sep arately ma nageable? I’m not su re the ans wer is yes . The clin ic infusio ns made me think of inpatient versus out patient. L ess about order type and more about deep er contact s.
	191	Jamie Crum ley: Well clinic inf usion is a n order ty pe.
	192	Scott Finl ey: I unde rstand but it is a h ybrid in t he sense t hat it has more to d o with the location in the con text of ca re. Anyway it still sounds lik e nobody c an think o f any orde rs to excl ude.
	193	Susan Scor zato: It s ounds that way. Let’ s move to that secon d question
	194	Which stat uses do we consider available for reassi gning?
	195	Hold, Flag ged, Pendi ng, Active Partial R esults, De layed, Unr eleased?
	196	Susan Scor zato: So a ny thought s?
	197	Scott Finl ey: The de eper quest ion is ess entially a ny orders on which f urther act ion or fur ther notif ication is expected needs a hu man for th at action or notific ation. If all of the se can hav e that hap pen, then they need to be able to be rea ssigned.
	198	Susan Scor zato: Okay .
	199	Jamie Crum ley: Okay so basical ly does ev erybody ag ree with t he theory of we can exclude fr om the rea ssignment any order that doesn ’t have a future pen ding actio n on it or can’t be acted upon . For exam ple, a can celled ord er, you ca n’t do any thing with that.
	200	Richard Ch o: Except for consul ts.
	201	Jamie Crum ley: Consu lts. Yes r ight, righ t. I was t hinking of other typ e of cance lled order s. It woul d be by se rvice basi cally. So there may be service s for ever y single o rder that someone ha s written that would have to b e reassign ed. But in some case s, if you got a canc elled medi cation ord er, they c an’t un-ca ncel that. They have to write another or der even i f it is by copying. There woul d be no re ason for m e to reass ign a canc elled medi cation ord er.
	202	Richard Ch o: You cou ld still f lag it, ri ght?
	203	Jamie Crum ley: But f or what pu rpose. Who you going to flag f or?
	204	Richard Ch o: I was j ust asking because y ou were sa ying if yo u no furth er action can be tak ing on the order, th en you can exclude i t.
	205	Jamie Crum ley: No fu rther acti on is expe cted. Firs t of all i t is not e asy to fin d them whe n they are cancelled medicatio n orders. You have t o do a cus tom view s ort of thi ng. Second ly, you wo uld have t o find it and flag i t and clas sify the e xact same person you wanted to flag to g o to. If y ou do that , then the response to that wi th the cha nges we ar e doing in v32 would come back to you. I n that par ticular in stance, th e ordering provider is kind of out of th e mix actu ally. Does that make sense?
	206	Scott Finl ey: Which is how it should be.
	207	Richard Ch o: So if I flag a ca ncelled or der and I send it to someone e lse, it’s going to c ome back t o me?
	208	Jamie Crum ley: Yes. It is a re sponse to the flag.
	209	Richard Ch o: Oh the response t o the flag . What abo ut my orig inal flag to ask a q uestion to the other person?
	210	Jamie Crum ley: It is going to go to whoe ver you se nt it to.
	211	Richard Ch o: Right s o I sent i t to the o rdering pr ovider.
	212	Jamie Crum ley: Okay that would be the ri ght person if you ar e trying t o ask the person who ordered i t.
	213	Scott Finl ey: It goe s to the d eadline of fice.
	214	Jamie Crum ley: No, t hat’s not right. Are you expec ting someo ne to flag a cancell ed medicat ion order?
	215	Scott Finl ey: You’re asking di fferent qu estions. I think it sounds lik e Richard is pointin g out that there is a possible activity here that is not yet handled i n the usua l way. The other que stion is: is there a plausible clinical scenario f or this.
	216	Jennifer Y ahnian: Ja mie, this is Jennife r Yahnian. On the EP S cancels like when patients h ave an add ress chang e, we do f lag those cancelled orders bac k to the p rovider.
	217	Jamie Crum ley: Cance lled order s for medi cations is an unsign ed orders and it is never sent anywhere. It is a c ompletely different thing.
	218	Jennifer Y ahnian: Yo u’re right .
	219	Jamie Crum ley: Conti nued order s absolute ly have fu ture actio ns on them , especial ly pharmac y orders b ecause the y could be reinstate d if they were disco ntinued du e to a pat ient movem ent. The c ancelled o rders I wa s talking about are the ones w here the p rovider wr ote the or der and ne ver signed it and we nt in and cancelled it. Those are the on es I was t alking abo ut.
	220	Jennifer Y ahnian: O kay. Then I can’t th ink of any scenario for that o ne.
	221	Jamie Crum ley: Disco ntinued du e to edit you can’t really do anything w ith those. You can f lag any or der. Are y ou suggest ing we mov e every si ngle order ever writ ten by a p rovider re gardless o f the orde r dialog o r the stat us?
	222	Scott Finl ey: Just f or fun we could turn the quest ion around again and argue tha t because we got fun ctionality that coul d potentia lly direct a message to the or dering pro vider and this order ing provid er can’t r eceive tha t message. You could make an a rgument fo r reassign ing all of them.
	223	Jamie Crum ley: You c ould and t he first t ime any of you try t o use this function, the entir e orders f ile would go back to the dawn of time I’ m pretty s ure you ar e going to come back and say w hat were y ou thinkin g.
	224	Scott Finl ey: You co uld have e xclude com pleted, I think.
	225	Jamie Crum ley: Well you can st ill flag t hose, too. There are n’t any re strictions on flaggi ng as far as I know.
	226	Richard Ch o: Well Ja mie just r eal quick on the bac k end is t his functi onality si milar to l ike if I r an a File Man report on the or ders file? It bogs t he system down. Maki ng this ch ange of re assignment will also affect th e system?
	227	Jamie Crum ley: Well if we make it search the entir e order fi le it will . We were hoping we could do s omething t o limit th e scope of how far b ack we wou ld have to search. I don’t mea n how far back we wi ll have to search bu t rather d o some thi ngs with c ross refer ences and things lik e that. We re you sug gesting to move ever y status o f every si ngle order since the dawn of t ime? When we install this patc h and we h ave to re- index the entire ord er style, it is prob ably going to be an issue.
	228	Jamie Crum ley: Will do whateve r you guys think is the right thing to d o.
	229	Richard Ch o: Don’t y ou still h ave to sea rch the wh ole thing in order t o get the four statu ses that w e wanted? So it stil l does tha t same sea rch, right ?
	230	Jamie Crum ley: No, n ot if you set up a c ross refer ence for e verything still whja t we would considere d an outst anding sta tus. If yo ur cross r eference c ontains on ly those i tems, you would only have to s earch that cross ref erence for that orde ring provi der basica lly.
	231	Sean McFar land: My o pinion is we don’t n eed to go back forev er. I thin k doing wh at we reas onable exp ect to tak e new acti on on is s ufficient there. We may not ge t every po ssible sin gle scenar io and I’m okay with that pers onally. I think we n eed to tak e into con sideration the syste m speed an d all that .
	232	Scott Finl ey: I don’ t think an ybody want s to bog d own the sy stem horri bly. Let m e ask abou t one clin ical scena rio. A lab order has been resu lted and e verything seems fine and then the lab se nds an ame nded resul t and some thing happ ened and s omething c hanged how they repo rt that. I n the mean time, the ordering p rovider ha s done a v anishing a ct and has been reas signed. Wh at about t hat order?
	233	Jamie Crum ley: Tell me again t he scenari o about wh at happen to the lab order.
	234	Scott Finl ey: The la b order wa s presumab ly treated as comple ted but th en another result co mes back a s an amend ed result.
	235	Jamie Crum ley: Do we do that w ith every lab order? I thought there was only anat omic patho logy, elec tron micro scopy, and things li ke that. W ould that happen wit h a chemis try test f or example ?
	236	Scott Finl ey: It cer tainly cli nically ca n happen. I can’t cl aim to kno w what we do in our system whe n it does.
	237	Richard Ch o: If the order is r eassigned, wouldn’t go to the new provid er?
	238	Scott Finl ey: Only i f it gets reassigned .
	239	Jamie Crum ley: I thi nk we woul d probably have to g o the lab folks to f ind out wh at the lab package a llows you to do. The lab packa ge allows you to edi t every si ngle type of order a fter you h ave comple ted it bec ause it ma y or may n ot. I know that some of them d o because you can at tach amend ed reports . For some reason, I didn’t th ink chemis try allows you to do that. We just have to check. It is poss ible on la b orders w e would ha ve to send everythin g.
	240	Richard Ch o: Same wi th radiolo gy, too, r ight? Imag ing?
	241	Jamie Crum ley: Imagi ng you wou ld you mos t likely w ould have to reassig n everythi ng because imaging a lways has integer re ports, you know.
	242	Richard Ch o: Right.
	243	Jamie Crum ley: Mike you never know about them. It’ s possible once we l ook and se e what’s o ut there a nd once we look and see what k ind of tax on the sy stem it is going to be, we wil l be requi red to set up some s ort of dat e limits s uch as don ’t go sear ch further back than a year or something like that . Or don’t reassign anything t hat’s over a year ol d. There i s some arg ument that certain p eople have that for a year it shouldn’t be valid a nyway for certain th ings. Like if you go t an order that is p ending for a year, t here are p eople who suggest th at it is n ot really a valid or der. I don ’t know ho w you guys feel abou t that.
	244	Richard Ch o: I know we have ha d some fai rly old im aging repo rts attend ed from th e past and potential ly have be en more th an a year.
	245	Jamie Crum ley: I was talking a bout pendi ng orders.
	246	Richard Ch o: Right, okay.
	247	Jamie Crum ley: There is some b ig cleanup going on now that g enerated a great dea l of relig ious argum ent. There are some people say ing if you got an or der out th ere that h as been si tting long er than X amount of time, you need to go and just cancel it or discont inue it. I know ther e is alway s those ar guments ab out how lo ng somethi ng should be valid.
	248	Richard Ch o: I know most of us think of this for l ab orders. I think t he lab pac kage might be hard-c oded now t o labs aft er a certa in period of time.
	249	Jamie Crum ley: I mad e that cha nge back i n my lab d ays here. It’s not h ard-coded it is a pa rameter se tting wher e you can decide bec ause that was one of the packa ges that h as some se rious back log of ord ers that w ere pendin g for year s and year s and year s. The lab said that they are not truly valid anym ore. The p rovider ne eded to re order them after a c ertain amo unt of tim e. But the sites cou ld never a gree on wh at that ti meframe wa s and so t hey made i t a parame ter.
	250	Scott Finl ey: But at a given s ite it is tantamount to hard-c oded even though it is paramet erized. Th at is to s ay there i s some amo unt of tim e after wh ich we wou ldn’t want to reassi gn them ne cessarily. So what I hear us d oing and t ell me if I am misre ading this we are oo zing over from statu s and orde r types to time limi t.
	251	Jamie Crum ley: Well not necess arily. I t hink the a nswer abou t the stat uses is ba sed on the order typ e for exam ple. I fee l like in the long r un we may end up wit h a combin ation of t hose thing s. Like yo u always s ign the pe nding orde r no matte r how old they are. You always reassign active ord ers no mat ter how ol d they are . You guys may come up with it some poin t in time. The disco ntinued or ders that Jennifer b rought up. Somebody might say I want you to reassi gn discont inued phar macy order s but not if they ar e a year o ld. That k ind of thi ng. Becaus e we don’t want to l ose the au to receive orders be cause of t he EPS thi ng. We don ’t want th ose to fal l by the w ayside. If they are over a yea r old for example le t’s say pr obably not auto rece ive or the y fell thr ough the c racks anyw ay. Eventu ally in ti me we coll ectively a s a group look at th ese we com e up with. Something that is a combinati on of all those. I c ould be wr ong but I just feel like it go ing to be sort of a hierarchic al thing t hat involv es more th an one cho ice. So Su san maybe we should table that one for n ow and mov e on to th e others. We would l ike to sho w everybod y the mock up before we leave.
	252	Susan Scor zato: Abso lutely. I agree. Let ’s go to t he next qu estion.
	253	How will t he provide rs be noti fied?
	254	Should the notificat ion be sen t to the t ransferrin g provider as well a s the rece iving prov ider?
	255	Jamie Crum ley: Well could we c larify thi s just a l ittle bit? There wa s one othe r requirem ents. You know I am going to b ack up wit h what I s aid lookin g at the t ime. We ha ve been he re 53 minu tes alread y. How abo ut if we t able the r est of the questions and just show the m ockup beca use I feel like that might get us some a ddition in put as wel l to get t he next mo ckup toget her and al so the nex t round of questions . Does any body think that’s a horrible i dea?
	256	Scott McFa rland: I t hink that’ s a good i dea.
	257	Susan Scor zato: We h ave a shor t amount o f time rem aining. Ca n you see on my scre en the win dow for re assign pat ients? (Ye s response ). This is a GUI pro totype to support th e reassign ment of pa tients fro m one prov ider to an other. I w ill show y ou exactly how this works. On the left h and side y ou got the Current P rovider or Former Pr ovider. Yo u can clic k down and click whi ch provide r you woul d like to select. On ce you sel ect the pr ovider you are looki ng for, un derneath y ou will se e a list o f patients with the outstandin g orders. Now with t his demo o n the righ t hand sid e with the New Provi der you wa nt to reas sign your patients t o you woul d go ahead and click the dropd own bar an d select t he provide r that you would lik e to reass ign your p atients to . Once you do that, the new pa tient prov ider assig nments wil l be in th e box belo w.
	258
	259	Susan Scor zato: So f or the nex t portion of this de mo, go bac k to the l eft and yo u can see the list o f patients in which you would like to as sign to Pr ovider 6. You have a couple of options h ere. You c an either drag and d rop, or yo u can sele ct and use one of th e middle b uttons (Ad d All or A dd Select) . That’s o ne way to do that. N ow if you look on th e left han d side of the tree y ou’ll see you have t hree remai ning patie nts. But y ou do not want these patients to go to P rovider 6. You want them to go to a diff erent prov ider so yo u will cli ck on the drop down and let’s say we wan t Provider 8 now to take care of these r emaining p atients. W e click Pr ovider 8 w hich you w ill see in the below screen un der the Ne w Patient Provider A ssignments . Again we can drag and drop o r you can click Add Selected.
	260	Susan Scor zato: Let’ s say at t his point in time yo u changed your mind because yo u made a m istake her e. You dec ided that Patient 1 needs to b e taken ca re of by P rovider 8 instead of Provider 6. You can also drop and drag. This is h ow you can move your patients around to each parti cular prov ider. If y ou decided that you do not lik e what you have chos en, you ca n click th e Undo All button. O nce you ha ve decided that thes e are the changes yo u have mad e and you want to co nfirm thos e changes, you would go ahead and click OK. Also, I believe we will be having a warning co me up that will stat e you have one remai ning patie nt that ne eds taking care. Aga in you can just sele ct that pa tient and do a drag and drop. Do we have any quest ions? I tr ied to mak e this as simple as possible a nd Scott, whom is ou r develope r, put thi s GUI prot otype toge ther for u s. Do we h ave any co mments?
	261	Scott Finl ey: My big gest worry and want to echo th at for the se kinds o f numbers of patient s it is a great UI a nd a numbe r of peopl e type tha t. We’ve g ot this ph rase outst anding ord ers and ou r prior co nversation suggests a potentia lly much, much large r set of o rders meet ing the cr iteria. If that happ ens, the n umber of p atients wi ll explode dramatica lly. I thi nk the UI may not wo rk so well with hund reds of pa tients as it does wi th tens or dozens.
	262	Susan Scor zato: You have a goo d point.
	263	Scott Finl ey: If eve ry patient I have wr itten a me d order fo r in the p ast year f or example , is now o n the list . That is a big list . I don’t think we h ave the ri ght UI for that. We have a gre at UI for small orde rs
	264	Jennifer Y ahnian: Ca n you add a filter f or types o f orders? But the wo rry would be they do n’t select all of th em. But yo u could li mit your l ist of pat ients by d oing that.
	265	Jamie Crum ley: But t hen they w ould have to go in h ere multip le times.
	266	Jennifer Y ahnian: I was just t hinking de finitely a Help Text for the t ype of ord ers that a re listing would be helpful.
	267	Jamie Crum ley: Remem ber that t his is not the final interface at all. I t is a moc kup to giv e you some ideas. I guess I am unclear. You are sa ying it is the wrong one. What do you fe el it is t he right o ne?
	268	Scott Finl ey: We hav e to work out whethe r we are s olving a p roblem for many of h undreds of patients or for doz ens. We ca n’t answer what’s th e right qu estion unl ess we kno w or they just diffe rent UI pr oblems.
	269	Jamie Crum ley: How w ould you a nticipate how we eve r figure t hat out?
	270	Scott Finl ey: We ran out of ti me to chat that one through un fortunatel y. Basical ly it amou nts to are we includ ing comple ted orders . That’s t he giant s et were po tentially including.
	271	Jamie Crum ley: You’r e still no t answerin g my quest ion of wha t do you b elieve the UI should be for hu ndreds of patients l et say.
	272	Scott Finl ey: I gues s you took more than five seco nds to des ign this v ery nice p iece. I do n’t have t he answer on the tip of my ton gue. We wo uld needs some tools for manag ing bigger lists.
	273	Richard Ch o: Is it p ossible to create an other inte rface to p ut in the criteria f or how to find the p atient and then be a ble to sor t that lis t? For exa mple, if I am part o f the pact and they split up t he patient s but some how I am a ble to ide ntify that , then I c ould group them toge ther as op posed to i f it is al phabetical , then I w ould have to scroll down and s kip and al l of that.
	274	Jamie Crum ley: I don ’t underst and what p act stands for so th at one is kind of tr icky for m e.
	275	Richard Ch o: What t ext stands for? The pact team? I’m sorry for PCMM. That’s an old term. It was li ke a butto n here to do a searc h for crit eria. I th ink that s hould be s omething t hat is add ressed. Is this UI f or a small group or for a big group?
	276	Scott Finl ey: There is another way to pa rtition it . It was a lluded to and the st art of it was sugges ted earlie r. Imagine if you co uld assign patients with activ e orders u sing this approach. Then you h ad a bulk approach f or handlin g patients , with the remaining ones that had, let’ s say, com pleted ord ers.
	277	Jamie Crum ley: I fee l like the people wh o would ha ve to do t his would probably n ot like to have to d o two thin gs. I coul d be wrong .
	278	Scott Finl ey: In man y cases, t hat would be faster than doing the one t hing assum ing you ne eded the f lexibility of this t ool. Right there lot s of patie nts who ju st haven’t been arou nd in a wh ile.
	279	Jennifer Y ahnian: Ja mie, you w ould still have a li st of pati ents that you need t o address. But it wo uld just b e for diff erent reas ons other than filte red by you r active p atients fi rst. What about some other ide ntifier sa y that 15 of your ne w patients have been reassigne d to a new provider. Maybe if you put th e new prov ider in th e second c olumn, the n it could show you which pati ents that you need t o move to that provi der.
	280	Jamie Crum ley: This was not on ly suppose d to addre ss just th at but oth er things as well. A nd the thi ng about i t is I kno w you guys think tha t having t o do two t hings migh t be faste r and peop le might l ike that m ore. But w e get comp laints if they have to click O K one more times.
	281	Richard Ch o: Those a re just th e clinicia ns.
	282	Jamie Crum ley: A Ser vice Chief is one of the antic ipated use rs.
	283	Richard Ch o: They ar e not goin g to be on es doing t his. It’s going to b e some Adm in person or a CAC o r a Progra m Manager.
	284	Jamie Crum ley: Last meeting th ey were ve ry clear i t would ne ver by the CAC doing this beca use they w ouldn’t kn ow how to.
	285	Scott Finl ey: Unless it is jus t a direct reassignm ent of all the patie nts, then it would b e straight forward. W hat’s a re alistic nu mber here? If we ar e included orders in the prior year, how many pati ents would a provide r have wri tten order s on in a year?
	286	Jamie Crum ley: Well I guess yo u can’t an swer that question w ithout kno wing who t he primary providers are that this is an issue for . Was the primary pu rpose of t his, empha sis for th is, inspir ation for this is to deal with the rotat ing staff like resid ence at te aching fac ilities or is it to deal with a primary care provi der that’s been on s taff for 1 0 years an d then ret ires. We w ould actua lly have t o go back to the ori ginal requ ester and see. What’ s the 90% you are go ing after?
	287	Laura Krou pa: I thin k for prim ary care p rovider wh o falls of f the face of the ea rth, most of that wo rk is goin g to be ha ndled by t he surroga te. That’s a whole c omprehensi ve set of things tha t a primar y care pro vider does for panel . The scen ario we ar e talking about is t he person hadn’t fal len off th e face of the earth but is in the facili ty in a di fferent ro le. The re sident who was on GI in Septem ber is now in Cardio logy in Oc tober. It is more ab out transf erring res ponsibilit ies for or ders and n ot respons ibilities for patien ts which i s what rea lly happen s with pri mary care folks.
	288	Richard Ch o: So in t he case of the resid ent if the y are stil l rotating , how woul d this dif ferentiate the order ? It almos t has to h appen in r eal time. The moment the resid ent goes t o the next service, somebody n eeds to ma ke this ch ange right away.
	289	Scott Finl ey: Otherw ise it wil l break th e orders t hat they w rote today .
	290	Jamie Crum ley: I men tioned tha t at the f irst of th e call. Th e tricky p art was if the provi der was ro tating fro m cardiolo gy to onco logy and t hey wrote a cardiolo gy order f or the sam e patient today that they wrot e for an o ncology or der for to morrow, so far the r equirement s that we were given in the NS R wouldn’t deal with that.
	291	Scott Finl ey: You wo uld need a n effectiv e date In order to h ave that m anaged.
	292	Jamie Crum ley: Right , exactly. That’s wh at we disc ussed earl ier. If th ey hadn’t written th is order i n two diff erent serv ices for t he same pa tient, tha t’s not go ing to be an issue. It’s only looking fo r orders t hat that p rovider wr ote. If th ey wrote a n order on e for Jane and one f or John to day and to morrow, th ey are goi ng to know that Jane is in car diology an d John’s o ver in onc ology. Tha t wouldn’t be quite so difficu lt to deal with. It’ s the one where they write a c ardiology order for Jane and a n oncology order for Jane two days apart that is k ind of the issue rig ht now. Th e date wou ld probabl y help us to deal wi th that.
	293	Scott Finl ey: Actual ly both of them will get you i n trouble with this UI. Whoeve r is filli ng this ou t, won’t n ecessarily know Jane from John . There is nothing h ere that s ays John i s in oncol ogy and Ja ne is in c ardiology. It’s work flow thing we got to think thr ough. By f iltering t his to ord ers writte n prior to date X, y ou get an effective date idea. You could at least make sure that the f irst two d ays of the ir service don’t get blown.
	294	Jamie Crum ley: We ar e ten minu tes over a n hour now . So if yo u guys got some issu es with th e interfac e and I un derstand t hat and yo u want som e time to think abou t it, we w ould reall y apprecia te if you could emai l us some suggestion s. That wo uld be tru ly helpful . Other th an that we should pr obably wra p up Susan . People a re needing to leave I suspect.
	295	Susan Scor zato: Yes, I agree. Let’s wrap this up. Thank you Jamie and thank you everyone f or attendi ng today. We appreci ate your a ttendance. If you co uld email us some of the quest ions after you think about it and also o n the prot otype we p rovided wi th you tod ay, we can address t hose quest ions, brin g them bac k to the t able and d iscuss the m further. Again tha nk you eve rybody. An y question s before w e end the meeting? I f we have no questio ns, I want to wish y ou happy g ood Friday and nice weekend.
	296	Conversat ion from C HAT WINDOW :
	297	Acker, Bet h Moodhard [2:15 PM] :
	298	I'm assumi ng this is only for signed ord ers. Corr ect? What happens t o somethin g that is unsigned?
	299	Agree
	300	McFarland, Sean A. [ 2:43 PM]:
	301	no please
	302	Hinton, Cr aig O. (HP ) [2:46 PM ]:
	303	need to dr op. thanks all.
	304	Crumley, J amie (HP) [2:46 PM]:
	305	Thanks, Cr aig.
	306	McFarland, Sean A. [ 2:47 PM]:
	307	will it go to XQAL UNPROCESSE D ALERTS
	308	McFarland, Sean A. [ 2:57 PM]:
	309	nice
	310	Cho, Richa rd [2:57 P M]:
	311	Really nic e:)
	312	How about: Double cl ick? SHift +Click to select? Mo use click+ hold to se lect?
	313	Laura Krou pa [2:59 P M]:
	314	Like it.
	315	McFarland, Sean A. [ 3:02 PM]:
	316	PCMM
	317	Cho, Richa rd [3:11 P M]:
	318	Would the "Provider" names hav e titles?
	319	Crumley, J amie (HP) [3:11 PM]:
	320	We haven't really go tten that in depth f or equirem ents yet, Richard.
	321	Cho, Richa rd [3:11 P M]:
	322	Much neede d function ality thou gh! Great start...
	323	Finley, Sc ott W. (BI TS) [3:12 PM]:
	324	Yes!
	325	Yahnian, J ennifer [3 :12 PM]:
	326	Excellent start on t he prototy pe. :)


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