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 #11 – Chemotherapy Order Management System (COMS)
July 11, 2014
2:00 – 3:06 p.m. ET
1.877.771.2574, Code 961.612.0419; https://global.gotomeeting.com
Name
Devin Harrison
Dr. Michael Kelley
Dr. Daniel Wu
Michael Cortright
Drew Myklegard
James Bullard
Patty Coke
Abraham Enfiedjian
Zach Forrest
Tina Gill
Eileen Gormly
Robyn Guy
Julie Hammond
Alicia Kim
Sharon Luikart
Ronald Major
Bobbie Masoud
Ed Null
Danielle Retland
Jamal Sangster
Sandy Shah
Teresa Stevens
Kristen Williamson
Mike Barlow
Sean Cassidy
Lou Ferrucci
Organization
VHA Innovation Program
VA – Durham VAMC
VA – Puget Sound HCS
VHA Innovation Program
VHA Innovation Program
VA
VA
VA
PWC
VA
VA
VA
VA
VA
VA
VA
VA
PWC
PWC
PWC
VA
VA
VA
dbITpro*
dbITpro*
CACI
Role
Contracting Officer Representative (COR)
Pilot Site Lead Innovator
Pilot Site Lead Innovator
Stakeholder
Stakeholder
Stakeholder
Stakeholder
Stakeholder
COR Project Support
Stakeholder
Stakeholder
Stakeholder
Stakeholder
Stakeholder
Stakeholder
Stakeholder
Stakeholder
COR Project Support
COR Project Support
COR Project Support
Stakeholder
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 11th 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.
Prototype COMS Stage 2 Demonstration
1
Author: Team CACI
Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System
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 11th sprint for the Stage 2
Enhancement Period to advance PoC COMS.
o The agenda is shown on slide 2.
o He noted today’s demonstration includes the four enhancements released for
presentation – 2 backlog items, one defect, and one miscellaneous enhancement.
 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: 29 Open, 35 Closed; 2 for presentation today
o Product Backlog – Prototype
 This list includes functionality requested by the current group of Prototype
COMS Stakeholders.
 16 Total: 9 Open, 7 Closed; 0 for presentation today
o Defect Log
 This list tracks application defects.
 47 Total: 28 Open, 19 Closed; 1 for presentation today
 He indicated the complexity of cumulative dosing functionality requires enhancements
to all five clinical modules plus Orders, Messaging, and Site Configuration. As the Team
explored solutions for cumulative dosing during the sprint, numerous business process
and functionality questions surfaced that warranted discussion with clinical
Stakeholders during today’s demonstration.
o In order to optimize development efforts, the Team deferred to clinical Stakeholder
input on preferred capabilities to incorporate feedback in finalizing the design and
developing software code enhancements.
o As a result of requirement uncertainties, three Product Backlog – PoC items were
deferred and will be presented during the next meeting.
 Lou provided an overview of the four items for presentation, as shown on slide 3. 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:
 Product Backlog – POC items
o Toxicity / Side Effects for Flow Sheet
Prototype COMS Stage 2 Demonstration
2
Author: Team CACI
Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System


Within the application, users document and view various aspects of the patient’s
progression throughout the regimen in the Flow Sheet (FS) Module. One of the
free-text fields for documentation is Toxicity / Side Effects.

Previous functionality permitted authorized users to select the Toxicity Side
Effect “Write” link to add an appropriate free-text narrative. When
completed, this entry becomes available to the entire healthcare team
through the “View” link.

The ability for users to select a specific toxicity/side effect from a list and
then comment on that selection was not previously available.
To demonstrate the clinician-facing functionality of this enhancement, Sean
selected a patient with an on-going regimen and opened the FS Module. He
then selected the “Write” link for Toxicity Side Effect.

Enhanced functionality displays a pop-up window to present a pull-down
menu, details, and free-text narrative field.
 The pull-down menu presents options for selection, as loaded in the Site
Configuration “Toxicity” panel.
 After selection of the toxicity from the pull-down menu, COMS displays
the selection and details loaded in Site Configuration for the selected
toxicity/level.
 Authorized users may add free-text narrative as “Comments” for the
selected toxicity and save the entry.

Once the Toxicity Side Effect documentation is completed and saved, COMS
changes the “Write” link to “View” for pop-up window display of the entry’s
selected toxicity, level details, and free-text narrative.

Eileen Gormly asked if the verbiage for the Toxicity pull-down menu was
standard and universally understood by clinicians.
 Sean responded he thought it was and Lou noted the verbiage can be
entered and modified, as desired, through Site Configuration.
 Dr. Kelley indicated the verbiage is well understood and is consistent
with common toxicity criteria. He elaborated that the levels typically
progress along a continuum – including mild, moderate, significant, and
severe – and include specific details for each respective toxicity. He
noted it would be nice to display the mild, moderate, significant, severe
verbiage with the level before making the selection, but not required.

During this portion of the meeting, Dr. Kelley introduced the overall topic of
Flow Sheet display and functionality. The results of the extended discussion
are as follows:
 Column headers designating cycle and day should be abbreviated to
conserve real estate. For example, “Cycle 1, Day 1” should be changed
to display “C1, D1”. This will be understood, without further definition,
by FS users.
Prototype COMS Stage 2 Demonstration
3
Author: Team CACI
Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System
Primary focus should be on what has happened – including held or
cancelled medications – vice what is scheduled. However, there is value
in being able to view scheduled administrations.
 For medications, administration of intravenous (IV) medications may be
presented differently than oral medications. IV medications should be
recorded with the dosage administered while it may be sufficient to
indicate the inclusive dates (e.g., first-last days) for oral medications.
 Stakeholders iterated the preference to collapse and expand the FS
display to conserve real estate, reduce scrolling, and enhance viewing.
 There are multiple open Product Backlog items related to Flow Sheet
functionality and display; no new requirements were identified.
 To demonstrate the administrative functionality of this enhancement, Sean
proceeded to the Toxicity panel within the Medications Sub-tab of the Site
Configuration Tab.

COMS Administrators may create/modify/delete toxicities and associated
details (via rich text edit field) for selection on the FS Module.

This administrative section provides functionality to manage (e.g., add, edit,
or delete) the toxicity pull-down menu options and verbiage presented in
the Toxicity Side Effect section of the FS Module.
o Entering Historical / Previous Dosing
 This requirement pertains to the functionality to enable entry of information
from previous administrations of medications being tracked for cumulative
lifetime maximum dosages. This may be for any administration provided
external to COMS (e.g., before COMS implementation and/or outside VA).
 To demonstrate this enhanced functionality, Sean continued with the patient
with an on-going regimen and proceeded to the Patient Information Panel.

Previous functionality did not provide any capabilities for medication
cumulative dose tracking.

Enhanced functionality now provides an “Add Medication” link to the newly
created Medication Cumulative Dose Tracking section. When a user selects
this link, COMS presents a pop-up window to enter previous dosing.
 Users are permitted to select the medication – as loaded in Site
Configuration “Cumulative Dose Medications” panel – enter numeric
value of medication administered to date, select the dosage units, and
enter the source of the information in the free-text field.
 Saved entries are immediately displayed in this section with specification
of total lifetime dose and information source for each medication.
 Sean indicated this functionality will be further refined with other
cumulative dose checking requirements to logically present the total
dosage entered into and administered through COMS.

Prototype COMS Stage 2 Demonstration
4
Author: Team CACI
Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System




To demonstrate the administrative functionality of this enhancement, Sean
proceeded to the Cumulative Dose Medications panel within the Medications
Sub-tab of the Site Configuration Tab.

COMS Administrators may create/modify/delete medications to be tracked
and their maximum lifetime dosages.

This administrative section provides functionality to manage (e.g., add, edit,
or delete) the Medication Cumulative Dose Tracking pull-down options
within the Patient Administration Panel. It also contains the values to be
ultimately used in cumulative dose checking and associated functionality.
o These two Product Backlog – PoC items were CLOSED, as presented.
Product Backlog – Prototype: There were none presented today for closure.
Defect Log items: The one Defect Log item presented today was within the Treatment
Documentation (TD) Module for (Medication) Grid Failed to Load.
o This defect pertained to the medication grid within the Administration Panel of the
TD Module that did not present dispensed medication information to facilitate
administration documentation.
o Using a patient with dispensed medications for an on-going regimen, Sean navigated
to the TD Module / Administration Panel. While demonstrating the loading and
rendering of the medication grid, he noted the Team is aware of a separate open
defect incorrectly displaying ordered dosages for those medications that are based
on body surface area (BSA) calculations (e.g., 200 mg/m2 ordered dosage vice the
410 mg calculated dosage).
o This Defect Log item was CLOSED, as presented.
Miscellaneous Enhancement
o Switch to High Contrast Mode
 Previous functionality presented COMS in Normal Contrast Mode without the
option to modify the display for improved visibility.
 Enhanced functionality provides the capability to present in high contrast mode
for an improved, 508-compliant display.

This capability is available by selecting the “Switch to High Contrast Mode”
link at the top of the application near the welcome statement.

Sean conducted the demonstration in High Contrast Mode to present this
miscellaneous enhancement.
 Stakeholders provided positive feedback for the high contrast display
with dark background and white text. Eileen Gormly suggested a black
background to further contrast with the white text.
 Feedback also indicated some Stakeholders would prefer a different
color scheme for normal contrast mode.

During the presentation, Sean noted some minor display concerns regarding
alignment within high contrast mode to be resolved during further 508
compliance enhancements.
Prototype COMS Stage 2 Demonstration
5
Author: Team CACI
Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System


The current default display is normal contrast mode and is available in high
contrast mode by selecting the “Switch to Normal Contrast Mode” link.
Sean asked if Stakeholders had any questions regarding today’s demonstration or
wanted to review anything. No additional comments, questions, or concerns from
Stakeholders were noted.
Lou Ferrucci thanked Sean for the demonstration. He then introduced the four questions
related to Cumulative Dose Checking on slide 4 for discussion.
 Clinical Stakeholders noted that certain medications have maximum cumulative lifetime
dosages that are generally accepted and considered “soft max”.
o The generally accepted maximum lifetime dosages are expressed in BSA-dependent
values (e.g., 500 mg/m2).
o Providers may exceed the generally accepted soft maximum as circumstances
warrant. COMS should provide the capability for the provider to document rationale
for exceeding the generally accepted maximum.
o In some instances, medications within certain classes (e.g. Anthracyclines) are
considered together when calculating and checking lifetime dosing. Sean asked if
the National Library of Medicine (NLM) medication lists include the classification.
 Stakeholders indicated the groupings are not inclusive.
 Dr. Kelley offered the solution to assign a “lifetime class” of medications within
COMS even though they may be in chemically different classes.
o Julie Hammond is continuing identification of the tracked medications and their
generally accepted maximum lifetime dosages. When finalized, she will send the
information to the Team.
 Stakeholders identified five primary points for advanced warning throughout the
patient’s regimen to notify the healthcare team of cumulative lifetime dose checking for
tracked medications.
o When a template is applied and the regimen’s scheduled course of treatment will
expose the patient to the maximum lifetime dosage.
o During the regimen, when 75% has been reached.
o During the regimen, when 90% has been reached.
o Throughout the regimen, with each administration after 90%.
o When 100% of the maximum lifetime dosage has been reached.
 Stakeholders expressed preferences for notification as follows:
o Pop-up alerts in real-time for initial and more critical notification points such as
when the template is first applied and reaching 100%. This functionality is preferred
to be similar to that for documentation of “No Adverse Reactions” when the patient
has a history of having adverse reactions. In addition to pop-up alerts for the user,
Stakeholders also preferred messages for the ordering provider.
o Messages to the healthcare team for the 75%, 90%, and subsequent percentages
notification points.
Prototype COMS Stage 2 Demonstration
6
Author: Team CACI
Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System
Lou noted the next sprint would focus on five Product Backlog – PoC items, as shown on slide 5.
 Three items deferred from the current sprint.
o Lifetime Cumulative Dosing for administrations within COMS.
o Cumulative Dose Checking for automated check of all entered/administered dosages
against maximum dosages for medications required to be tracked.
o Flow Sheet for Nurse Role to display information for “held” or “cancelled”
medications.
 Two additional enhancements for Flow Sheet functionality.
o Relevant Flow Sheet Data to enhance display of relevant laboratory results and
entered narratives.
o User Ability to Tailor View (Flow Sheet) to provide more/less abstract view of
information.
In wrapping up the meeting, Lou noted no new Prototype COMS items were identified for the
Product Backlog and stated the next demonstration meeting will be August 1, 2014. He elicited
further Stakeholder comments and provided the opportunity for the Lead Innovators and
Innovation Coordinator/COR to provide any closing comments.
 Julie Hammond asked if the issue of VA users accessing the Innovations Sandbox from
within the VA domain has been resolved.
o Sean Cassidy indicated the Team is still addressing the issue, coordinating with the
Sandbox support staff, and working towards modifying sessions to write information
to the COMS database instead of the user’s work station.
o Lou noted the Sandbox support staff advised VA users to access the Sandbox via
Google Chrome or Mozilla Firefox. However, Stakeholders indicated most facility’s
only approve loading the Internet Explorer browser
 Dr. Luikart mentioned she was able to access COMS within the Sandbox, but unable to
load a patient.
o Sean stated the Team’s solution to overall access will increase navigation speeds.
o He also confirmed the Team is continuing efforts to migrate away from using the
Medical Domain Web Services (MDWS) to query VistA; the enhanced query process
will also accelerate interoperability between COMS and VistA.
 There were no closing comments offered by Dr. Kelley, Dr. Wu, or Devin Harrison.
 There were no further comments offered by other Stakeholders.
Lou concluded the meeting by thanking Stakeholders for attending this Stage 2 Demonstration.
The meeting concluded at 3:06 p.m. ET.
Attachment:
Meeting Slide Deck
Prototype COMS Stage 2 Demonstration
7
Author: Team CACI