Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System
Event
Date
Time
Location
Attendees
Stage 2 Demonstration #10 – Chemotherapy Order Management System (COMS)
June 20, 2014
2:00 – 3:00 p.m. ET
1.877.771.2574, Code 961.612.0419; https://global.gotomeeting.com
Name
Devin Harrison
Dr. Michael Kelley
Janet Cogswell
Julie Hammond
Alicia Kim
Bobbie Masoud
Molly McCarthy
Ed Null
Craig O’Brien
Danielle Retland
Sandy Shah
Tina Gill
Samuel Robinson
Stanley Zucker
Mike Barlow
Sean Cassidy
Lou Ferrucci
Organization
VHA Innovation Program
VA – Durham VAMC
VA
VA
VA
VA
PWC
PWC
VA
PWC
VA
VA
VA
VA
dbITpro*
dbITpro*
CACI
Role
Contracting Officer Representative (COR)
Pilot Site Lead Innovator
Stakeholder
Stakeholder
Stakeholder
Stakeholder
COR Project Support
COR Project Support
Stakeholder
COR Project Support
Stakeholder
COR Invited Guest
COR Invited Guest
COR Invited Guest
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 tenth 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 several new attendees and for any additional attendees
participating in groups.
 He indicated today’s demonstration was the result of the tenth 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 seven enhancements released for
presentation – three backlog, one defect, and three miscellaneous items.
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: 33 Open, 31 Closed; 3 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; 1 for presentation today
He indicated two other Product Backlog – POC items involving Flow Sheet functionality
were worked during this sprint but not released for demonstration today. The two
deferred items will be presented during the next meeting as development efforts within
the Flow Sheet module diverted to focus on overall functionalities and display.
Lou provided an overview of the seven 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 Selection of Intelligent Data Elements
 Within the application, users document patient vital signs through either the
Patient Vitals Panel or the Vital Signs grid within the Treatment Documentation
(TD) Module / General Information Panel. These entries, or those imported from
VistA, are used to calculate the patient’s Body Surface Area (BSA).

Previous functionality automatically used the most current vital signs to
calculate the patient’s BSA and, subsequently, BSA-calculated medication
dosages, as appropriate.

The ability for users to select specific height/weight entries was not
previously available.
 To demonstrate this functionality, Sean selected a patient with an on-going
regimen and opened the Patient Information Panel. He then selected the
“Update BSA” link to select different data elements for the calculation.

Enhanced functionality displays the BSA calculations pop-up window and
provides a link to “Select different Height/Weight from Vitals”. Selection of
this link presents another window with pull-down menus to change the
height/weight for BSA calculations.
Prototype COMS Stage 2 Demonstration
2
Author: Team CACI
Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System
Heights and weights are listed in standard and metric values with the
date obtained. The default height/weight is that used to calculate the
BSA currently displayed in the Patient Information Panel.
 Cancelling the action or saving without changes will return to the
original BSA Calculations display.
 Selecting different values and saving will update the BSA Calculations
display and update the BSA value on the Patient Information Panel.

This functionality is also available via the “Show Calculations” link.
 Bobbie Masoud asked if only actual weights may be specified or if other weight
methodologies (e.g., ideal, lean, other) may be used.

Sean indicated the weight methodology is specified for each patient’s
regimen at the time the template is applied.

He demonstrated functionality to specify the weight methodology by
selecting a patient without a current regimen. Users may select one of five
weight methodologies – actual, ideal, lean, adjusted, or other.
o Warning of Adverse Reaction History
 This requirement pertains to the functionality for selection of “No Adverse
Reactions” – through the Assessment Panel and Infusion Reactions Panel within
the TD Module – to display a warning if the patient has a history of adverse
reactions during the regimen.
 To demonstrate this enhanced functionality, Sean continued with the patient
with an on-going regimen and proceeded to the TD Module / Assessment Panel.

Previous functionality permitted specification of adverse events/reactions
without the capability to notify the user of a history of adverse reactions.

Enhanced functionality now provides a check box option for the user to
specify “No Adverse Reactions”. When a user selects this box and the
patient has had a history of adverse reactions during the current regimen,
COMS now alerts the user and prompts to confirm the response.
 Users are permitted to return to the panel, review their responses to
either document a reaction or specify no adverse reaction, and save.
 Sean indicated this functionality will be further refined to permit the
user to confirm and save in one step or return to the panel to document
the patient’s adverse reaction.
 This “No Adverse Reactions” check box functionality exists on the Assessment
Panel and Infusion Reactions Panel after the list of options to document adverse
events since last treatment or infusion reactions, respectively.
o Adverse Reaction Alert
 This requirement pertains to the prominent display of an adverse reaction alert
with capability to provide detailed information for user review/consideration.
 To demonstrate this enhancement, Sean opened the Adverse Events History
Panel for the same patient with an on-going regimen. This panel and its
functionality did not exist prior to this development sprint.

Prototype COMS Stage 2 Demonstration
3
Author: Team CACI
Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System

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

Enhanced functionality now presents the Adverse Events History Panel with
number of records within the panel and number flagged to trigger an alert
readily displayed whether the panel is collapsed or expanded.

The total number of records within the panel is displayed in standard blue
font text (e.g., “4 Adverse Events Recorded”) and the number of records
flagged to trigger an alert is displayed in red font text immediately
afterwards (e.g., “- 1 flagged to trigger an Alert”).

The expanded panel presents adverse events chronologically within the
categories of “Assessment” or “Reaction” as initially documented in the TD
Module’s Assessment Panel or Infusion Reaction Panel, respectively.
 Within the “Assessment” category, detailed information is presented for
the date of the event, selected level, and any comments entered
through the TD Module/Assessment Panel.
 Within the “Reactions” category, detailed information is presented for
the date of the event, section (e.g., extravasation), and any comments
entered via the TD Module/Infusion Reactions Panel.
 Adverse events flagged for alert are displayed in prominent red font text
immediately above the detailed information for each category.

The Adverse Events History Panel is specific to the patient’s treatment
regimen, as defined by the template currently applied.
o These three 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 for Incorrect Weight
Units Displayed in BSA Calculation.
o This defect pertained to calculations within the BSA Calculation window (accessed
through the “Show Calculations” link within the Patient Information Panel) displayed
with incorrect units; the actual calculations were correct.
o After presenting all other enhanced functionality, Sean returned to the Patient
Information Panel for the patient with an on-going regimen. He selected the “Show
Calculations” link and noted the units displayed were properly labeled as “kg”.
o This Defect Log item was CLOSED, as presented.
Miscellaneous Enhancements
o Indication of No Adverse Reactions
 Previous functionality for the Assessment Panel and Infusion Reactions Panel
within the TD Module permitted documentation of adverse events since last
treatment and reactions to today’s administration, respectively. To document
no adverse reactions, users saved the panel without checking any boxes to
indicate an adverse event or reaction.
 As noted above in the Warning of Adverse Reaction History section, enhanced
functionality now requires users to take “positive action” to document no
adverse reactions. This is achieved by selecting the check box displayed
immediately above the save button at the bottom of the panel.
Prototype COMS Stage 2 Demonstration
4
Author: Team CACI
Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System

o Laboratory Results Display within Flow Sheet
 Previous functionality included laboratory results in the grid display for
information obtained/entered on administration days. However, while
developing the Flow Sheet (FS) Module functionality during this sprint, the Team
identified the need to improve the laboratory results display.
 Enhanced functionality relocated laboratory results to a dedicated FS panel to
permit more inclusive viewing. When the panel is expanded all laboratory test
results throughout the regimen are presented regardless of day (i.e. rest day or
administration day).
o Integrated Use of Local VistA Instance’s National Library of Medicine (NLM) Drug List
 Previous functionality utilized specific, “hard coded” outpatient and inpatient
medication lists available for selection of pre-therapy, therapy, and post-therapy
template medications.
 Enhanced functionality provides more tailored and dynamic medication listings.
COMS now integrates the use of the local VistA Instance’s NLM drug list.

This capability provides for the exact same list as the facility’s VistA and
eliminates “casing issues” (i.e. capitalization or lower case) for medication
selection and the passing of medication actions between COMS and VistA.

Responding to a Stakeholder question, Sean indicated users retain access
throughout any update COMS Administrators process in the system.

Julie Hammond asked about the addition of non-formulary medications,
noting medications are not available in VistA until the build is requested and
performed by the ADPAC. Sean noted COMS can add non-formulary
medications; he will ensure the functionality is congruent with VistA
processes and reach out to Julie if he has any questions.

Bobbie Masoud asked if additions to the local COMS instance will write to
the national formulary.
 Sean indicated COMS cannot write to the national formulary and utilizes
a local drug file based on the VistA instance.
 He elaborated that if there is a requirement to write non-formulary
medications to the national formulary, the Team can work towards
providing that functionality.
Sean asked if Stakeholders had any questions regarding today’s demonstration or
wanted to review anything.
o Stanley (Stan) Zucker noted the progress/advancement of COMS and inquired about
the time frame for deployment and use.
 Sean stated the pilot location deployments are scheduled for Durham VAMC and
VA Puget Sound Health Care System in December 2014.
 Devin Harrison announced VA is working towards further expansion and
sustainment of COMS and will setup a meeting to discuss in more depth.
o Stan asked if his facility should be looking at buying a chemotherapy application
product.
Prototype COMS Stage 2 Demonstration
5
Author: Team CACI
Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System

Devin encouraged him and other Stakeholders to hold off on purchasing any
chemotherapy application product.
 Dr. Kelley noted the substantial cost of purchasing licensing for chemotherapy
application products. He further stated COMS is an open source solution fully
funded for enhancement and pilot location deployment; emphasis now is to
finish enhancements then conduct the pilot deployments to advance the
innovation; and the timeline for expanded COMS deployments is unknown.
o The functionality demonstration concluded after no further discussion or questions.
Lou Ferrucci thanked Sean for the demonstration. He then noted the next sprint would focus
on five Product Backlog – PoC items, as shown on slide 4.
 Two items deferred from the current sprint.
o Flow Sheet for Nurse Role to display information for “held” or “cancelled”
medications.
o Toxicity/Side Effects for Flow Sheet to permit truncated search capabilities to
annotate one or more toxicities/side effects.
 Three enhancements for cumulative lifetime dosing.
o Lifetime Cumulative Dosing for administrations within COMS
o Entering Historical/Previous Dosing for administrations external to COMS
o Cumulative Dose Checking for automated check of all entered/administered dosages
against maximum dosages for medications required to be tracked.
 Lou noted the medications listed on slide 4 are projected to be tracked.
 Dr. Kelley asked if designations of medications to be tracked will be editable.

Lou confirmed designations will be editable and noted the medications on
the slide were from initial research.

Julie Hammond agreed to work with the Team to validate this initial list and
identify other medications currently required to be tracked.
Lou introduced the three PoC COMS Product Backlog items on slide 5 for discussion.
 (Peripherally Inserted Central Catheter) PICC Line
o This item was originally identified during Government testing in 2012. It specified
several aspects of PICC Line care to be documented within COMS, similar to an
earlier requirement to capture intravenous (IV) flush activities.
o Dr. Kelley indicated the requirement seemed outside the scope and solicited input
from other clinical Stakeholders.
 Julie Hammond expressed agreement, but noted PICC Line care is required to be
documented in the patient record.
 Janet Cogswell agreed, stated there will always be additional documentation to
be done directly in CPRS, and agreed with Dr. Kelley.
 Sean navigated to the TD Module / IV Site Panel to further facilitate discussion.

Janet noted the panel currently provides the option (non-mandatory) for
entering free text narrative to document PICC Line or other IV site care.
Prototype COMS Stage 2 Demonstration
6
Author: Team CACI
Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System
She further indicated different facilities specify information required to
satisfy data collection and infection control monitoring; noting the optional
free text field on the IV Site Panel appears appropriate and sufficient.
 Dr. Kelley concluded current functionality would satisfy documentation needs
and the PICC Line requirement is out of scope.
o Devin Harrison agreed with the discussion and conclusion. He instructed the item
should be closed without further consideration or enhancement activity.
Relevant Flow Sheet Data and User Ability to Tailor Flow Sheet Views (these two items
were discussed together)
o These two items were originally identified during Government workshops prior to
PoC COMS development. Lou stated the Flow Sheet currently includes all desired
data points identified to the Team and presents the information in a logical display.
He requested Stakeholders review and provide input on content and presentation.
o Sean navigated to the Flow Sheet and Lou provided a brief overview of the content
and information display.
 Dr. Kelley stated he might prefer a title different than “Other” as the third field
for narrative comments and the addition of a row or two for additional
narratives. He also indicated that receiving all laboratory results within COMS
may be more information than is useful for chemotherapy as specific test results
are typically viewed and shouldn’t get lost with presentation of others.

Bobbie Masoud suggested the option to identify desired laboratory results
relevant for each chemotherapy regimen/template.

Sean indicated he would discuss solutions for narrative rows and lab results
with the Team and present options to Stakeholders.
 Dr. Kelly asked about viewing for regimens with numerous administration dates
and noted the default view should be for “today” or to the right instead of the
first administration date.

Sean indicated the Flow Sheet is scrollable and will be set for a default view
of “today” (to the right instead of the left with first administration date). He
also demonstrated the external Flow Sheet accessible through the Order
Entry Management (OEM) Module. Presented in a new browser tab, the
external Flow Sheet provides a larger display and is focused on “today”.

Dr. Kelley requested a link to the external Flow Sheet be added to the Flow
Sheet Module Chemotherapy/Biotherapy Header. Sean confirmed the link
will be added.
No further questions or concerns from Stakeholders were offered on these three
product backlog items.



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 July 11, 2014. He elicited
further Stakeholder comments and provided the opportunity for the Lead Innovators and
Innovation Coordinator/COR to provide any closing comments.
Prototype COMS Stage 2 Demonstration
7
Author: Team CACI
Veterans Affairs Center for Innovation
VHA Innovation Program
Chemotherapy Order Management System

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Dr. Kelley thanked Stakeholders for their attendance and noted the application is
“looking good”.
Devin Harrison echoed Dr. Kelley’s appreciation for Stakeholder attendance.
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 3:00 p.m. ET.
Attachment:
Meeting Slide Deck
Prototype COMS Stage 2 Demonstration
8
Author: Team CACI