Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System
Event
Date
Time
Location
Attendees
Stage 2 Demonstration #9 – Chemotherapy Order Management System (COMS)
May 30, 2014
2:00 – 2:55 p.m. ET
1.877.771.2574, Code 961.612.0419; https://global.gotomeeting.com
Name
Devin Harrison
Dr. Daniel Wu
James Bullard
Zach Forrest
Eileen Gormly
Robyn Guy
Alicia Kim
Bobbie Masoud
Molly McCarthy
Ed Null
Craig O’Brien
Jamal Sangster
Carol Weitz
Mike Barlow
Sean Cassidy
Lou Ferrucci
Organization
VHA Innovation Program
VA – Puget Sound HCS
VA
PWC
VA
VA
VA
VA
PWC
PWC
VA
PWC
VA
dbITpro*
dbITpro*
CACI
Role
Contracting Officer Representative (COR)
Pilot Site Lead Innovator
Stakeholder
COR Project Support
Stakeholder
Stakeholder
Stakeholder
Stakeholder
COR Project Support
COR Project Support
Stakeholder
COR Project Support
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 ninth 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 ninth sprint for the Stage 2
Enhancement Period to advance PoC COMS.
o The agenda is shown on slide 2.
o He specifically welcomed the attendees from Minneapolis VA Health Care System as
our newest Stakeholders, offering perspective gained from use of a COTS product.
o He noted today’s demonstration will include the four enhancements released for
presentation.
Prototype COMS Stage 2 Demonstration
1
Author: Team CACI
COR Pr
Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System



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: 37 Open, 27 Closed; 4 for presentation today
o Product Backlog – Prototype
 This list includes functionality requested by the current group of Prototype
COMS Stakeholders.
 13 Total: 6 Open, 7 Closed; 0 for presentation today
o Defect Log
 This list tracks application defects.
 46 Total: 28 Open, 18 Closed; 0 for presentation today
He indicated another Product Backlog – POC item enhanced during this sprint was not
released for demonstration today 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 Intelligent Data Entry Detection
 Within the application, users may record patient vital signs through either the
Patient Vitals Panel or the Vital Signs grid within the Treatment Documentation
(TD) Module / General Information Panel.

Previous functionality permitted any numeric entry for temperature, height,
weight, systolic/diastolic blood pressure, pulse, and respirations; entries for
pain are limited to 0 through 10 and saturation percentages for peripheral
oxygen entries may not exceed 100.

The ability to set variance and/or value parameters with user alerts was not
previously available.
 To demonstrate the clinical functionality of this enhancement, Sean selected a
patient with an on-going regimen and proceeded to the TD Module. He then
used the General Information Panel grid and intentionally entered abnormal vital
sign values to exceed the parameters established in Site Configuration.

Enhanced functionality presents a red underline alert with message for each
entered value exceeding specified Site Configuration parameters. Users
may “mouse over” the red underline alert to review the message.

If users choose to save vital signs with entries exceeding the value/variance
parameters, COMS presents a pop-up message to indicate one or more
entries exceed specified parameters and permits users to cancel the save
action to modify entries or proceed with the save action, as appropriate.
Prototype COMS Stage 2 Demonstration
2
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 IDE (Intelligent Data Entry) tab within the Site Configuration Tab.

COMS Administrators may create/modify/delete vital signs configurations
for intelligent data entry detection based on specified values or variances.
These configurations include the capability to specify the alert message for
any of the three intelligent data parameter checks.
 Minimum/Maximum Value to detect entries out of the specified clinical
range.
 Percentage Variance from Value to detect entries exceeding identified
variance of the specified clinical value.
 Percentage Variance from last Entry to detect entries exceeding
identified variance from the patient’s last assessment/vital signs entry.

COMS will accommodate site preferences for detection of one, two, or all
three of the intelligent data parameter checks and performs these checks
concurrently without priority.
 Eileen Gormly asked a few questions for clarification of this functionality.

Lou explained there are three intelligent data checks that may be set in Site
Configuration to accommodate local facility preferences to detection and
alert messages. Users are prompted to validate entries exceeding specified
parameters and permitted to save these entries following their validation.

Sean noted the checks are dependent on the Site Configuration settings;
they may be specified for patient specific detection – such as last entry – for
clinical recommendations – such as minimum/maximum values and/or
variance from specified value – or all the above.

Mike Barlow clarified the functionality of each detection method as being
independent of one another with alert messages displayed, as appropriate,
when entries exceed Site Configuration parameters.
o Height Confirmation
 COMS users may record height as part of patient vital signs through either the
Patient Vitals Panel or the Vital Signs grid within the TD Module.

Previous functionality permitted any numeric entry and did not compare the
entry to previous entries.

The ability to set and/or check variance parameters was not previously
available. Functionality enhancements for intelligent data detection/height
confirmation now enables COMS to check for height variances to confirm
accuracy of entries. With proper Site Configuration, COMS will alert users to
an entry that exceeds Site Configuration parameters comparing the current
entry to the last entry (e.g., new entry of 60 inches for a 6 foot tall patient
with historical height entries of 72 inches will trigger an alert, if specified).
 As a component of Intelligent Data Detection, Height Confirmation capabilities
are enhanced for vital signs entry and Site Configuration, as discussed above.
Prototype COMS Stage 2 Demonstration
3
Author: Team CACI
Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System
o Drill Down Items
 This requirement pertains to the capability to print patient discharge instructions
and appointment reminders from the TD Module.
 To demonstrate this enhanced functionality, Sean continued with the same
patient with an on-going regimen and proceeded within the TD Module to the
Discharge Instructions Panel.

Previous functionality permitted documentation of various details for
discharge instructions and specify future follow-up appointments; however,
it did not offer print functionality.

Enhanced functionality now provides links to “Print Discharge Instructions”
and “Print Follow-up Appointment”, as entered and saved in the Panel.
 With selection of either link, COMS opens a new browser window/tab to
display the selected information. Users may use browser functionality
for saving or printing the information for the patient then close the new
browser window/tab when no longer needed.
 Information for “Print Discharge Instructions” includes patient name,
upcoming appointments and laboratory tests scheduled, clinic
information and discharge instructions selected in the Discharge
Instructions Panel, medication specific information relevant to the
regimen, and any other free text comments added in the Panel.
 Information for “Print Follow-up Appointment” includes patient name,
upcoming appointments and laboratory tests scheduled, and clinic
information selected in the Discharge Instructions Panel.
o Staging Designation
 Within the application, authorized users may specify the type of cancer and
disease stage when creating/modifying regimen templates through the Template
Authoring Tab or Chemotherapy Template Order Source (CTOS) Module.

Previous functionality permitted users to enter free text staging designation
without regard for type of cancer associated with the template regimen.

Similar to Type of Cancer selection, enhanced functionality now provides a
pull-down menu for staging designation in a clinically, contextual manner
(i.e., staging designations are linked to specific cancer types).
 To demonstrate the provider-facing functionality for Staging Designation, Sean
navigated to the Template Authoring Tab, selected the radio button to Create a
New Template, and selected a type of cancer from the pull-down menu.

Enhanced functionality now provides users with contextual options within
the Cancer Stage pull-down menu.

Sean presented the Extensive Stage and Limited Stage options for Small Cell
Lung Cancer and contrasted those to the seven different options (I – IV with
multiple alpha suffixes) for Non-Small Cell Lung Cancer.
 To demonstrate the administrative functionality of this enhancement, Sean
proceeded to the Disease Staging tab of the Site Configuration Tab.
Prototype COMS Stage 2 Demonstration
4
Author: Team CACI
Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System
COMS administrators may use the text field to specify disease staging for
any type of cancer, enabling contextual options during template authoring.

This administrative section provides functionality to manage (e.g., add, edit,
or delete) the disease staging designations for specific cancer types available
for selection in the Template Authoring Tab and CTOS Module.
o These four Product Backlog – PoC items were CLOSED, as presented.
Product Backlog – Prototype: There were no Product Backlog – Prototype items
presented today for closure.
Defect Log items: There were no Defect Log items presented today for closure.
Sean asked if Stakeholders had any questions regarding today’s demonstration or
wanted to review anything. After no further discussion or questions, he concluded the
functionality demonstration.




The two items on slide 5 for discussion and clarification were presented at different times
during the presentation.
 VistA Interoperability
o This item was presented intermittently around connectivity issues with the VistA
instance within the Innovation Sandbox.
o Using the same patient with an on-going regimen and administration day of today,
Sean demonstrated interoperability for orders by presenting various screens within
COMS and VistA.
 He opened VistA, selected the same patient with an on-going regimen, and
navigated to Orders to show VistA did not have any medication orders finalized
or dispensed for today.
 Using the same patient within COMS, he proceeded to the Orders Tab and noted
today’s orders for the patient were not finalized or dispensed.

He then advanced one medication order to an Order Status of “Finalized”
and noted a future enhancement will provide one “Update” button for all
medications instead of the current functionality requiring users to update
each medication order update individually.

At the request of Bobbie Masoud, Lou explained the continuum of orders
within COMS.
 Medications are ordered by the provider, cleared by a member of the
healthcare team, and finalized by the pharmacist.
 Finalized orders are passed to VistA for preparation; once they are
dispensed in VistA, the order passes back to COMS with an order status
of “Dispensed”.
 Dispensed orders are available on the TD Module / Administration Panel
for documentation of the medication’s administration.
 Administered medications and dosages are displayed on the Flow Sheet
for review by the healthcare team and the End of Treatment Summary
worksheet for provider reference in preparing the treatment summary.
Prototype COMS Stage 2 Demonstration
5
Author: Team CACI
Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System


After identifying a hang up with the transmission of the order, Sean reconnected
to VistA and retrieved the patient’s medication order.

The finalized order was passed from COMS to VistA after the patient record
was no longer open in VistA.

In response to James Bullard’s question, Sean stated COMS functionality
uses FileMan and Remote Procedure Call (RPC) routines to pass orders to
the Inpatient Pharmacy Module within VistA.
 One Stakeholder attendee noted the medication dosage/quantity passed to
VistA was different than that within COMS and the order was unsigned.

Sean indicated orders passed from COMS to VistA are currently unsigned.
The functionality to sign/co-sign orders within COMS will be enhanced
during an upcoming Stage 2 sprint.

He elaborated that orders functionality will be enhanced, resolved, and
presented to Stakeholders at a future demonstration meeting.
Medication Reminders
o As presented after Projected Activities for the Next Sprint and VistA Interoperability
demonstration, this PoC COMS Product Backlog requirement is to prompt providers
to check on the status or requirement for other adjunct/ancillary medications, as
required for certain chemotherapy regimens. Lou asked Stakeholder providers for
feedback on functionality preferences for this projected enhancement.
 Carol Weitz indicated the current COTS application at Minneapolis prompts
providers when signing off on the regimen’s days/cycle for administration.

Bobbie Masoud elaborated that the application allows users to build
chemotherapy regimens with differing cycles that accommodate periodic
use of adjunct/ancillary medications.

Sean stated COMS could be modified to provide capability to identify
different medications for various cycles within a regimen template. Lou
noted the requirement had not been previously identified, but he would
coordinate with Devin Harrison, Dr. Kelley, and Dr. Wu to see if it should be
considered for the Prototype COMS Product Backlog.
 No further questions or concerns from Stakeholders were offered.
While Sean was trouble shooting connectivity issue and hang up of the order transmitted to the
VistA instance, Lou presented the five Product Backlog – PoC items for the next sprint, as shown
on slide 4.
 Originally projected for this demonstration, Selection of Intelligent Data Elements will
be completed and presented to permit selection of height/weight entries to use for
Body Surface Area (BSA), and ultimately medication dosage, calculations.
 Enhancements for Warning of Adverse Reaction History and Adverse Reaction Alert will
communicate information regarding a selected patient’s history with adverse reactions.
 Flow Sheet enhancements will provide medication hold/cancel information for a
patient’s treatment regimen, as the last remaining component of Flow Sheet View for
Prototype COMS Stage 2 Demonstration
6
Author: Team CACI
Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System
Nurse Role. Toxicity/Side Effects for Flow Sheet will refine capabilities to enable users
to perform a truncated search as part of this documentation narrative.
In wrapping up the meeting, Lou noted no new Prototype COMS items were identified for the
Product Backlog; however, he would coordinate with Devin Harrison, Dr. Kelley, and Dr. Wu on
the items being surfaced from the Minneapolis VA Healthcare System’s use of the COTS
application. He stated the next demonstration meeting will be June 20, 2014, elicited further
Stakeholder comments, and provided the opportunity for the Lead Innovators and Innovation
Coordinator/COR to provide any closing comments.
 Dr. Wu extended his appreciation for participants attending the demonstration and
providing feedback for items to improve functionality.
 Devin Harrison echoed Dr. Wu’s comments, thanked Stakeholders for their attendance,
and noted the good feedback to enhance functionality towards project success.
 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 2:55 p.m. ET.
Attachment:
Meeting Slide Deck
Prototype COMS Stage 2 Demonstration
7
Author: Team CACI