Download COMS Module Review Minutes

Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System
Event
Date
Time
Location
Attendees
Stage 2 Demonstration #13 – Chemotherapy Order Management System (COMS)
August 22, 2014
2:00 – 2:35 p.m. ET
1.877.771.2574, Code 961.612.0419; https://global.gotomeeting.com
Name
Devin Harrison
Dr. Michael Kelley
Dr. Daniel Wu
Duane Baskin
Patty Coke
Seginald Bryant
Tina Gill
Eileen Gormly
Julie Hammond
Alicia Kim
Ronald Major
Molly McCarthy
Ed Null
Jamal Sangster
Dave Thomas
Earl Young
Mike Barlow
Sean Cassidy
Lou Ferrucci
Organization
VHA Innovation Program
VA – Durham VAMC
VA – Puget Sound HCS
VA
VA
VA
VA
VA
VA
VA
VA
PWC
PWC
PWC
VA
VA
dbITpro*
dbITpro*
CACI
Role
Contracting Officer Representative (COR)
Pilot Site Lead Innovator
Pilot Site Lead Innovator
Stakeholder
Stakeholder
Stakeholder
Stakeholder
Stakeholder
Stakeholder
Stakeholder
Stakeholder
COR Project Support
COR Project Support
COR Project Support
Stakeholder
Stakeholder
Senior Developer, Development Team
Technical Architect, Development Team
Project Manager, Development Team
*dbITpro is a subcontractor for Team CACI
Purpose and Attachments
Demonstration for the 13th development sprint of Stage 2 Enhancements for Prototype COMS
T4-0299 project (VA118-1007-0014). The attached slide deck provides the agenda for this
meeting to demonstrate advancement of Proof of Concept (PoC) COMS.
Minutes
Lou Ferrucci opened the meeting by welcoming attendees to the demonstration.
 Verifying attendance through the GoToMeeting log, he requested information via
GoToMeeting messaging for any additional attendees participating in groups.
 He indicated today’s demonstration was the result of the 13th sprint for the Stage 2
Enhancement Period to advance PoC COMS.
o The agenda is shown on slide 2.
Prototype COMS Stage 2 Demonstration
1
Author: Team CACI
Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System




o He noted today’s demonstration includes the seven enhancements released for
presentation – two PoC COMS Product Backlog items, three defect items, and two
miscellaneous enhancements.
Lou provided an overview of the status of enhancement and development activities, as
stratified into the following three categories:
o Product Backlog – PoC
 These 64 items were originally identified by PoC COMS Stakeholders and agile
development efforts will “burn down” this backlog to 0 Open and 64 Closed.
 64 Total: 25 Open, 39 Closed; 2 for presentation today
o Product Backlog – Prototype
 This list includes functionality requested by the current group of Prototype
COMS Stakeholders.
 16 Total: 8 Open, 8 Closed; 0 for presentation today
o Defect Log
 This list tracks application defects.
 50 Total: 29 Open, 21 Closed; 3 for presentation today
He stated the team has also completed two miscellaneous enhancements.
o Addition of Intravenous (IV) fluid type and volume information to the Chemotherapy
Template Order Source (CTOS) Module display.
o Location for Clinic Information within the Treatment Documentation (TD) Module’s
Discharge Instructions Panel.
He indicated the Product Backlog – POC item projected for this sprint to display held and
cancelled medications on the Flow Sheet Module (Flow Sheet (FS) View for Nurse Role)
was worked during this sprint but not released for demonstration today.
o While addressing a related, known defect related to Hold and Cancel actions, the
team determined Orders Tab functionality required attention. This was productive
for overall COMS capabilities, but resulted in delay of this Product Backlog item.
o This enhanced functionality will be presented at the next demonstration.
Lou provided an overview of the seven items released for presentation today, as shown
on slide 3.
o He thanked Julie Hammond for providing the list of chemotherapy medications to
track throughout the patient’s lifetime and the recommended maximum dosages for
each. These medications and values have now been loaded in Site Configuration to
further enable functionality for cumulative lifetime dosing.
o He noted additional medications for cumulative lifetime dosing were added for the
sole purposes of development testing and demonstration. Similar to testing
templates, the medications and maximum values are clinically fictional.
o He introduced Sean Cassidy to provide the demonstration of enhanced functionality.
Sean Cassidy welcomed Stakeholders, thanked them for attending the meeting, and provided
the demonstration of the following COMS enhanced functionality:
Prototype COMS Stage 2 Demonstration
2
Author: Team CACI
Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System

Product Backlog – POC items. Given the interdependent nature of the two lifetime
dosing capabilities for demonstration, enhanced functionality for Lifetime Cumulative
Dosing and Cumulative Dose Checking were presented together.
o The Lifetime Cumulative Dosing requirement pertains to the capability to capture
lifetime dosing of tracked medications for administrations within COMS. The
complementary requirement to account for administrations external to COMS was
presented during the August 1, 2014 demonstration as Entering Historical/Previous
Dosing. When added together, these values represent the total cumulative dosing
for each patient. Cumulative Dose Checking delivers the capability to check these
added values/cumulative doses and notify the healthcare team of those instances
approaching or exceeding the maximum values loaded in Site Configuration.
o To demonstrate enhanced functionality to provide a healthcare team warning for
patients approaching or exceeding a maximum lifetime dose for a tracked
medication, Sean presented two different patient scenarios.
 For a patient with an on-going regimen that does not include tracked
medications or includes tracked medications with lifetime dosing below 75%, a
warning is neither warranted nor displayed.
 For a patient with an on-going regimen that includes a tracked medication with
the patient’s lifetime dosing equal to or exceeding 75%, COMS displays a
Cumulative Dose Warning in red text immediately beneath Patient Selection and
above Patient Information that is persistent for all “Patient” actions.

This prominent warning lists the medication, recommended maximum,
patient lifetime total, and percentage (calculated as lifetime total divided by
recommended maximum).

The Cumulative Dose Warning will display every time the selected patient’s
regimen contains a tracked medication with the patient’s lifetime dosing
equal to or exceeding 75%.
 For any patient, COMS provides cumulative lifetime dosing medication in
Medication Cumulative Dose Tracking section of the Patient Information Panel.

This section displays the medication, maximum dosage, cumulative lifetime
total, component values for amount received, and source information for
each component value (e.g., “administered and tracked via COMS on
08/22/2014” or text provided when entering historical/previous dosing).

This section provides functionality for authorized users to enter historical/
previous dosing by selecting the “Add Medication” link, as presented during
the previous demonstration.
 Pull-down menu for medication is limited to those tracked medications
entered in the “Cumulative Dose Medications” tab of Site Configuration.
Refined functionality now presents the recommended maximum lifetime
dosage and unit of measurement (e.g., mg/m2, units) from Site
Configuration.
Prototype COMS Stage 2 Demonstration
3
Author: Team CACI
Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System
The free-text numeric entry for historical dose is qualified/modified by
the specified unit of measurement designated in Site Configuration. In
this manner, all entries for historical dosing should be provided
consistent with the unit of measurement to be tracked.
 Source of Information is a free-text field for the user to specify where
they obtained the historical information (e.g., patient VA records).
 Once saved, this information is displayed immediately and anytime the
Patient Information Panel is opened for the specific patient.
o To demonstrate the functionality enhancement for capturing lifetime dosing of
tracked medications administered within COMS, Sean continued with the patient
with an on-going regimen that included a Cumulative Dose Warning for the patient’s
lifetime dosing of a tracked medication equal to or exceeding 75%.
 He navigated to the Treatment Documentation (TD) Module / Administration
Panel to administer medications dispensed for this patient.

After an authorized user signs a medication record for administration of a
tracked therapy medication, the Medication Cumulative Dose Tracking
section of the Patient Information Panel is immediately updated.

With each administration, the Cumulative Dose Warning for any tracked
medications within the regimen is immediately updated. The displayed
lifetime total and percentages match those listed in the Medication
Cumulative Dose Tracking section of the Patient Information panel.
 The TD Module / Administration Panel and the Medication Cumulative Dose
Tracking section of the Patient Information Panel work together to provide
Cumulative Dose Checking information for tracked medications throughout the
patient’s regimen, to include a Cumulative Dose Warning for the patient’s
lifetime dosing of a tracked medication equal to or exceeding 75%.
o To demonstrate the application’s proactive communication and clinical decision
support of cumulative lifetime functionality dosing prior to applying a template,
Sean selected a patient to apply a template for a prescribed treatment regimen.
 Enhanced functionality provides cumulative medications for each regimen in a
dedicated section of the CTOS Module immediately above the “Apply Template
to Patient” button.

For regimens without tracked medications, this section notes “No
Cumulative Dose Tracked Medications in this Regimen”.

For regimens with tracked medications, this section lists the medication,
lifetime maximum, details for the regimen (i.e., total per cycle and total per
regimen), details for the specific patient (i.e., patient’s lifetime total,
whether the regimen is projected to exceed the recommended maximum
lifetime dosing, and the percentage), and a red text warning, as appropriate,
to indicate the regimen will exceed the lifetime maximum, the exceeding
dosage value/unit of measurement, and the percentage.

Prototype COMS Stage 2 Demonstration
4
Author: Team CACI
Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System

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
This functionality provides information to the provider before beginning a
treatment regimen to promote an informed decision prior applying a template.
o These two Product Backlog – PoC items were CLOSED, as presented.
Defect Log items
o Failure to Save Infusion Reactions Panel
 This defect pertained to COMS displaying an error when saving the Infusion
Reactions Panel within TD Module.
 Proceeding with the patient with an on-going regimen, Sean presented resolved
functionality to permit saving of this panel.

After he selected an infusion reaction and the save button, COMS properly
prompted to identify infusion reactions that may trigger an adverse event.

During this presentation, the Adverse Events History Panel did not
immediately re-render the updated information. The team will investigate
and resolve and/or open a new defect item, as appropriate.
o Failure to Save Discharge Instructions Panel
 This defect pertained to the saving action of the Discharge Instructions Panel
within TD Module presenting an error and not saving entered information.
 Proceeding with the same patient with an on-going regimen, Sean presented
resolved functionality for saving this panel and its associated actions.

Selection of Clinic Information via pull-down menu, as detailed below in
Miscellaneous Enhancements.

Selection of radio button options to indicate whether discharge instructions
were provided, specifying details, as appropriate.

Indication of follow-up appointment and specifics, as applicable.
o Inability to Apply Template
 This defect pertained to the automatic refresh of information once a template
was applied to a patient. The defect required the user to manually refresh the
application to present information from the newly applied template.
 To demonstrate resolution of this defect, Sean applied a new template to a
patient without a template currently assigned.

He selected the patient, proceeded to the CTOS Module, and selected a
template to apply.

COMS applied the template to the patient and refreshed the display with
updated information in the Patient Information panel, as designed.
 During this portion of the presentation, Eileen Gormly asked if pull-down menus
and other functionalities were accessible via keyboard (i.e. not exclusive to
mouse operations). Sean demonstrated and confirmed COMS supports
keyboard tabbing/selection actions as well as mouse actions.
o These three Defect Log items were CLOSED, as presented.
Miscellaneous Enhancements
o Add Fluid Type to CTOS Display
Prototype COMS Stage 2 Demonstration
5
Author: Team CACI
Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System


Previous functionality for the CTOS display of Pre-Therapy, Therapy, and PostTherapy medications included the IV fluid volume, but not the IV fluid type.
 While presenting functionality to resolve the defect for Inability to Apply
Template, Sean selected multiple templates and noted the CTOS display.
Enhanced functionality now includes the IV fluid type and volume for all IV and
IV piggyback (IVPB) medications in the regimen.
o Location for Clinic Information
 Previous enhancement for the Discharge Instructions Panel within the TD
Module included the addition of Clinic Information. However, this pull-down
menu was only available when the user expanded the Patient Education section
of the panel.
 Enhanced functionality now displays the Clinic Information pull-down selection
menu immediately before the Patient Education section.

While presenting resolution of the defect for Failure to Save Discharge
Instructions Panel, Sean demonstrated this miscellaneous enhancement.

COMS now displays the pull-down menu for selection of Clinic Information
(as loaded in Site Configuration) above the Patient Education section. With
this enhancement, users may now specify clinic information independent of
documentation for the provision of Discharge Instructions.
Sean asked if Stakeholders had any questions regarding today’s demonstration or
wanted to review anything. No additional comments, questions, or concerns – relevant
to functionality and/or presentation – from Stakeholders were noted.
Lou Ferrucci thanked Sean for the demonstration. He then noted the next sprint would focus
on six Product Backlog – PoC items, as shown on slide 4.
 FS View for Nurse Role to display information for “held” or “cancelled” medications.
 Template Change Impact on Patients to alert providers to patients with ongoing
regimens potentially affected by applied template changes.
 Rolling Changes to Administration Dates to effect administration date changes to
subsequent dates in the cycle and/or regimen.
 Medication Reminder to provide capability to remind providers to check on status or
requirement for adjunct medication(s) at prescribed intervals.
 Medication Administration Sequencing to provide ordinal indication for sequencing to
serve as checklist for administration.
 Allergies and Drug Interactions to provide capability to cross-check drug interactions
and allergies with known drug allergies and prescribed medications in VistA.
Lou introduced the topic of Medication Reminders for discussion/clarification as it relates to
enhancement activities for the next sprint, as shown on slide 5.
 The requirement for this Product Backlog – PoC item is to provide the capability to
remind providers to check on the status or requirement for adjunct medication(s) at
prescribed intervals during a patient’s regimen.
Prototype COMS Stage 2 Demonstration
6
Author: Team CACI
Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System

o Lou provided the example of prompting the provider to assess the patient for the
potential addition of B12 treatment.
o He then elicited Clinical Stakeholder clarification whether they prefer notifications to
be provided through COMS messaging or VistA functionality. Dr. Kelley stated he
prefers CPRS alerts since the notice may be missed in the volume of VistA messages
or if the provider is not logged into COMS.
 Eileen Gormly stated many providers at VA Puget Sound Health Care System
forward VistA messages to their Microsoft Outlook va.gov account. Dr. Kelley
noted that the forwarding feature would be beneficial for VistA messaging.
 Eileen further noted a parallel effort with COMS messages being forwarded to
CPRS alerts and/or VistA messaging may serve as a safeguard to convey the
medication reminder over multiple mediums.
 Julie Hammond noted the difference between CPRS alerts and VistA mail.
Sean indicated he will research the possibility of relaying COMS messages through
existing VA electronic health record alert/notification capabilities.
In wrapping up the meeting, Lou noted no new items were identified for the Prototype COMS
Product Backlog. He stated the next demonstration will be September 19, 2014, resulting in a
4-week sprint to accommodate the Association of Veterans Affairs Hematology and Oncology
(AVAHO) Conference. He elicited further Stakeholder comments and provided the opportunity
for the Lead Innovators and Innovation Coordinator/COR to provide any specific comments on
cumulative dosing and/or closing comments.
 Dr. Wu stated the concept and information for cumulative dosing is there and
Stakeholders will need to use COMS to become more familiar with its capabilities and
presentation/display of the information.
 Dr. Kelley noted cumulative dosing looks fine and agreed Stakeholders will need to
access the application.
 Devin Harrison thanked attendees for participating in today’s meeting and providing
feedback; he wished everyone a great weekend.
 There were no further comments offered by other Stakeholders.
Lou concluded the meeting by echoing the need for Stakeholders to explore Sandbox COMS
and provide feedback to help ensure it provides the robust functionality required to support VA
oncology services. He then thanked Stakeholders for their attendance and concluded the
meeting at 2:35 p.m. ET.
Attachment:
Meeting Slide Deck
Prototype COMS Stage 2 Demonstration
7
Author: Team CACI