The Background
The US client is a Joint Commission accredited behavioral health care organization. This 400-bed hospital is certified to provide treatment by the US Centers for Medicare and Medicaid Services. Psychiatric and medical care is provided to adult, geriatric, forensic, adolescent and child patient populations. Social work, psychology, therapies, pharmacy, lab, radiology, dental, vision, nutrition and other services are provided. This teaching hospital has psychiatry resident training for two universities. It provides training rotations for medical students, nurses, social workers, psychologists, physical therapists, occupational therapists, recreational therapists and chaplains.
The hospital had no funding available for a proprietary electronic health record. But in 2013 the client successfully implemented open source VistA in-house without assistance from an integration vendor. As a result, they retained total control of enhancements, maintenance, and operational support enabling fast in-house response. The hospital maintains 100% clinician adoption and exceptionally high levels of end user satisfaction throughout all disciplines. Their continuous in-house end-user training, help desk and informatics support has helped achieve this. Based on VistA and other components of their electronic health record framework the client achieved and maintains HIMSS Stage 6 certification.
The hospital had made a pioneering and courageous decision to implement VistA, against the popular clamor to go for expensive proprietary solutions. This success has avoided the enormous cost of vendor lock-in and dependence; truly in the best interest of a State hospital, run on taxpayer money.
The Need
VistA addresses most requirements in a large hospital. However, this Behavioral Health client had one mission critical need that it did not cater to effectively. The client had spent several years of reviewing Vendor provided solutions for a suitable Master Treatment Planning technology. The treatment planning model needed to be integrated with VistA based on the following six (6) guiding principles:
Interdisciplinary;
Individualized to meet the patient’s needs;
Problem and strength focused;
The treatment planning process should enable direct involvement by the patient;
Driven by assessment data;
The treatment plan is directed toward the patient’s discharge.
A team of psychiatrists, social workers, psychologists, nurses, and pharmacists work together with the patient and family/guardian to develop a comprehensive Master Treatment Plan.
This Master Treatment Plan requires frequent scheduled plan review, renewals, and updates during the patient’s hospital stay. VistA allows this to be done using its templates feature, but does not provide features that allow for a user-friendly collaborative documentation and update processes.
At the time that Edgeware Technologies met the client, the hospital was documenting the Master Treatment Plans and updates generally on paper. Some of the psychiatrists were preparing the document using Microsoft WORD. All Master Treatment plans and updates were signed on paper. There was no method to electronically relate intervention and progress notes in VistA to the problems, goals, and interventions specified in the current paper Master Treatment plan. All 400 patients required multi-page documents with continuous and frequent multi-disciplinary collaborative updates. The client had determined that scanning and attaching the document to a note in VistA was not feasible or desirable. The result was that the Master Treatment Plan was the only critical document stored in the paper chart and not available in VistA.
The Solution
Edgeware Technologies offered to adapt their existing VistA based Multi-Disciplinary Treatment Plan to the needs of the client. The adaptation required changing from the MySQL database to the MS SQL database used by the hospital. Also needed was the capturing of patient registration through an HL7 interface from Quadramed through a MIRTH engine for patient admission, discharge and transfers. The hospital required the use of an Enterprise ID and password for each user to login to their VistA system in place of the standard access and verify codes used in VistA. This uses the Microsoft Active Directory to connect to VistA. Integration with VistA is accomplished primarily using the standard VistA RPC calls.
The new highly efficient work-flow made possible with this solution is as follows:
The VistA-Edge treatment planning application permits overall control through the clinical dashboard. This shows the status of patients that are due or overdue for a Treatment Plan. The hospital policy mandates that a newly admitted patient have an initial treatment plan prepared within 24 hours and a formal Master Treatment Plan to be created immediately after. The Master Treatment plan is required to be frequently reviewed and updated on a scheduled basis. The VistA-Edge clinical dashboard enables team members to quickly identify the patients whose plans are due for creation or updating.
A tight integration between the VistA-Edge application with the client’s installation of VistA eliminates the need for double entry of clinical information. Information already documented in VistA is readily available in VistA-Edge. This includes automatically pulling the Medical and DSM diagnoses, the allergies, and active medications from VistA into the Master Treatment Plan application. Patient demographics are automatically populated in the Master Treatment Plan using the HL7 provided registration information.
E-signatures and user credentials are automatically obtained from VistA. In the Treatment Plan application any licensed clinician with the needed credential can initiate the process of generating a new plan. He/she by default becomes the treatment planning coordinator and can add others to the team as desired. During the course of the process, existing team members can be retired or replaced by new members. The treatment planning coordinator role can be easily reassigned. Team members or to any other staff in the hospital can also be assigned interventions.
In the VistA-Edge treatment plan application, multiple users can work on the treatment plan from separate locations, saving as draft, to prepare for the collaborative treatment team session and update process.
With user friendly screens, the treatment team rapidly documents the patient’s strengths and assets, psychosocial stressors, anticipated needs upon discharge, crisis plan, participation of patient and family/guardian in the planning process and the hospital staff that attended the treatment planning session.
The treatment team enters problems, long term goals, short term goals and interventions in the VistA-Edge treatment plan application. Problems are the basis of identifying Long Term Treatment Goals. Each Long Term Goal has associated Short Term Goals. Each short term goal can have one or more Interventions.
The VistA-Edge Treatment Plan application sends team members notifications in VistA, the moment any event relating to a plan they are associated with is performed. This includes notifications of required e-signature for treatment team hospital staff participants. Staff who did not attend the treatment planning session are also assigned planed interventions. These staff will receive notifications in VistA.
Once the treatment team is satisfied with the plan, it is “Finished” and signed by the treatment plan coordinator and the members of the treatment team. They use their VistA electronic signature codes in the VistA-Edge application. The plan is then complete and posted to VistA, where it is viewed in the Notes Tab. A professionally formatted version of the Master Treatment Plan can be printed from the VistA-Edge treatment plan application.
The Master Treatment plan update sessions use the renewal function in the VistA-Edge treatment plan application. All Problems, Long Term Goals, Short Term Goals and Interventions that are not completed are contained in the renewed plan. So also, previously entered information, except for patient and family/guardian participation from the prior plan, is brought forward into the renewed plan. This process efficiently prepares a base plan that allows for modification of all carried over information.