Introduction

Clinical Procedures (CP) is a new VistA package that provides features that can be used across clinical departments, such as general medicine, cardiology, pulmonary, women’s health, neurology, and rehabilitation medicine. CP is a conduit for passing patient results, using HL7 messaging, between the vendor and VistA.  Patient test results are displayed in the Computerized Patient Record System (CPRS).  CP includes three modules, which are CP User, CP Manager, and CP Gateway.

CP User is the primary application that clinicians use.  For example, you can place an order for a procedure, such as an EKG, in the Consults application.  Then you can use CP User to check in patients and initiate the actual procedure. If the procedure is performed on a bi-directional instrument, the patient demographics are automatically transmitted to the instrument.  When the procedure is complete, the result is transmitted back to VistA Imaging and attached to a TIU note that is associated with the original Consults order.

If the procedure is performed on a uni-directional instrument, you use CP User to match the instrument results to the procedure.  The TIU note is created when the instrument results are submitted to VistA Imaging.  Standard Consults functionality is used to complete and sign the TIU note.  The main purpose of CP User is to link the results from the automated instrument to the procedure ordered through Consults in CPRS.

System managers and clinical application coordinators use CP Manager.  The main purpose of this application is to add and edit automated instruments and procedures in the CP database.  CP Manager is also used to configure the site files and required system parameters.

CP Gateway manages the flow of information from the instrument interfaces to patient records.   CP Gateway polls the system regularly for new data from instruments and processes this data into usable attachments for the VistA Imaging system.


Ordering a Consult Procedure in CPRS

This section describes how to order a CP procedure through CPRS. Keep in mind that you can only order a CP procedure as a procedure and not as a consult because a CP procedure is physically performed on the patient.  A consult is ordered for the patient but is not physically performed.

In addition to becoming familiar with the CPRS ordering process, you can learn about the interpreter, the new user role within Consults that supports CP.  The interpreter is a new User Role created by ASU that defines a user who can interpret the procedure’s final result.  Clinical application coordinators define interpreters in the Consults package.  If you are an interpreter for a specific procedure, you can receive an alert when the consults are ready for review and interpretation.  The following example describes how to order a colonoscopy procedure through the CPRS Consults tab.

1.	Logon to CPRS.  The Patient Selection window is displayed.

2.	Select a patient.  Notice that Clark Kent is the selected patient.  The Cover Sheet window is displayed.

3.	Click the Consults tab at the bottom of the window.

4.	If you want to review an existing procedure, select one of the consults or procedures from the panel in the upper left.  The lower left panel contains any supporting documents for the selected consult, and the larger right panel contains the order details.

5.	Click New Procedure on the left side of the Consults tab. Since Clark Kent is an inpatient, the Order a Procedure window is displayed.  Go to step 7 to order the procedure.

(If you were to select an outpatient, the Location for Current Activities screen displays so you can enter a location. Go to step 6.)

6.	For Outpatients, select either the Clinic Appointments or New Visit tab.
- Select Clinic Appointments if the patient already has an appointment through Scheduling.
- Select New Visit if an appointment has not been made through Scheduling, and then select a location from the list of Visit Locations. The Encounter Location is filled in automatically.
- If the patient had existing admissions, these are displayed under the Hospital Admissions tab.
- Go to step 7 to order the procedure.

7.	To order the colonoscopy procedure, select Colonoscopy from the Procedure dropdown list.

- Complete the appropriate fields.
- Click Accept Order.
- Click Quit.

8.	To sign the consult procedures, select File > Review/Sign Changes.

- Click the appropriate check boxes to select the colonoscopy.
- Enter your electronic signature code.
- Click Sign to return to the Consults tab. At this point, the procedure becomes an order.

9.	Click the Orders tab to review the consult procedures.  These consult procedures appear on the Active Orders sheet.


Working with CP User

This chapter describes how to get started with CP User.

Topics discussed in this chapter are:

•	Defining CP User Icons

•	Selecting a Patient

•	About the CP User Main Window


Defining CP User Icons

 Select View > Use Toolbar.

  Open Patient – Opens a new patient record.

  Refresh Patient - Refreshes the currently selected patient’s information.

  Check-in New Study - Checks-in a patient and opens a new study.

  Open Study - Opens a currently selected study.

  Delete Study - Deletes a currently selected study.

  Help - Provides on-line help for this package.

  Clinical Procedures Home Page - Goes to the Clinical Procedures Home Page on the Web.


Selecting a Patient

1.	Open CP User.

2.	Select File > Open Patient.  The main CP User screen lets you select a patient that has a consult procedure ordered.  You can choose Patient, Team, Clinic, or Ward.

-	Choose Patient if you want to select a patient by name, complete SSN, or first initial of the last name and the last four digits of the SSN.

-	Choose Team if you want to select a patient from a list of teams defined in the OE/RR List file (#100.21).

-	Choose Clinic if you want to select a patient from a list of clinic appointments for a predetermined clinic and date.

-	Choose Ward if you want to select a patient from a list of MAS wards.

3.	Double-click the patient’s name.  A confirmation screen is displayed, which shows additional information about the selected patient.  If you select a sensitive patient, a sensitive patient window is displayed that describes patient information on a need to know basis.

4.	Click OK.  The main CP User window is displayed.


About the CP User Main Window

In this main window, you can select a treating specialty folder from the left and view a list of procedures within that treating specialty on the right.  Click the column headers to sort them in ascending or descending order.

The status column displays New, Submitted, Error, Ready to Complete, Pending Instrument Data, and Complete.  Here is a description of each status type.

•	New - (The New status is only available with VistA Imaging.) A study has been requested by VistA Imaging and needs to be checked-in and submitted to an instrument.  Example: You scanned in a consent form through the VistA Imaging Capture Workstation.  A new CP Study record is created along with a TIU document.

•	Submitted - This study has been submitted to the VistA Imaging Background Processor.  The study report waits in the Imaging Background Processor queue to be copied or processed and placed on the VistA Imaging server.  A study in this status is not accessible until VistA Imaging returns a status of Complete or Error and logs any errors encountered in the submission process.

•	Error - This study has encountered an error while being submitted to VistA Imaging.  The error may have been caused when the TIU note was created, when a visit was created, when the results were linked to the procedure, or when the attachments were sent to the VistA Imaging server.  Error messages are logged with the study and can be reviewed by opening the study in an error status.

•	Complete - This study has successfully created a TIU note for interpretation and images have been sent to VistA Imaging for the selected consult procedure order.  If any attachments were included, they have been successfully copied to the VistA Imaging server.

•	Pending Instrument Data – (This status is only valid for bi-directional instruments that have not returned results.) The procedure request has been submitted to a bi-directional instrument and is waiting for the instrument to return the results. Studies in this status should not be opened until the instrument has returned the results, assigned them to the study, and marked the study as Ready to Complete.

- If the "Auto Submit to VistA Imaging" checkbox is selected for the associated procedure in CP Manager, the study goes to Complete.
- If the "Auto Submit to VistA Imaging" checkbox is not selected for the associated procedure in CP Manager, the study goes to Ready to Complete.

•	Ready to Complete –
When a study is done on a uni-directional instrument, the status displays as Ready to Complete.

When a study is submitted to a bi-directional instrument, the study remains in Pending Instrument Data status and changes to Ready to Complete after the study has received the data from the instrument.  (Auto Submit to VistA Imaging is not selected.)

In the Ready to Complete status, you can open the study, view the Consult/Procedure order, and manually submit instrument results and external attachments to VistA Imaging.

A study can be deleted when it has a status of  "Pending Instrument Data".  A study should be deleted only if the study was sent to the wrong instrument, or if the patient was unable to complete the procedure.  Select File > Delete Study and click Delete.  A cancel order is sent to the device.  If that device is not working, you must manually delete the order from the device. Refer to the manual for your specific instrument for instructions on deleting an order.


How the Clinical Procedures Process Works

This topic describes the process to follow for ordering clinical procedures.  (Although you can order several types of procedures in CPRS, you must follow these steps to order clinical procedures.)  The tasks in all of the following topics  use the example of ordering a colonoscopy test to describe the Clinical Procedures process.  Be sure to follow the required steps in sequential order.  You can do the optional steps as needed.

1.	Order a consult procedure in CPRS.  Required

2.	Check in a new study.  Required

3.	Update study status to correct errors.  Optional

4.	Complete the Procedure.  Required

a.	Enter the Interpretation into the TIU note. Required

b.	Enter Encounter information.  Required for workload counts

c.	Sign off.  Required

5.	View Clinical Procedures results.  Optional

6.	Link consent forms and images to Clinical Procedures documents.  Optional


Check in a New Study

You need to check in a new study in CP User after a procedure has been ordered through Consults. Checking in a new study is the next step in the Clinical Procedures process.

If you want to link multiple results to one procedure, you can check in multiple studies for the same procedure that you ordered through Consults. A warning screen displays telling you that this consult procedure order has already been checked in. After you ensure that you have the correct consult procedure order, you can continue to check in the study. In this way, you do not have to order multiple procedure requests.

In this example, the colonoscopy procedure was ordered and a new study for the colonoscopy procedure is being checked in.

1.	To check in a new study, first logon to CP User and select the patient.

2.	Choose File > Check in New Study to check in the patient.

3.	Select a consult for the selected patient.  The Clinical Procedure column lists the consult procedure order requests in reverse chronological order by date/time.

Note:  You can only select from Clinical Procedure request orders that are in the Pending, Scheduled, Partial Results, Complete, and Active statuses.  Discontinue and Cancelled statuses are excluded.  (c = complete, p=pending, s=scheduled, pr=partial results, and a= active).

If the consult procedure order you selected has already been checked in, a warning screen displays. After you ensure that you have the correct consult procedure order, you can continue to check in the study.

4.	Depending on the consult you selected, the appropriate instruments for that procedure are displayed.  Click the appropriate instrument if more than one is listed, or click No Instrument if no instrument is associated with this procedure.

5.	You must associate the CP study with a visit, which is the hospital location where the procedure was performed.  Required.

For the majority of TIU notes created through CP, the visit association is completed in the background.  If a visit has already been recorded but the note wasn’t linked (standalone visits, such as telephone or walk-in visits), you can select a visit from the Clinical Procedures Check In edit screen.

To link the TIU note to the visit, select information from the Outpatients Visits tab.  You can also select the New Visit tab and enter NOW for the date and time.

6.	Click Check-In. The main CP User window is displayed.

7.	If the study is checked-in for a uni-directional instrument, the status is Ready to Complete. If the study is checked-in for a bi-directional instrument, the status is Pending Instrument Data.  (The colonoscopy status is Pending Instrument Data since the colonoscopy uses a bidirectional instrument.

8.	At this point, the clinician performs the procedure on the instrument and transmits the results back to VistA.

If the instrument is bi-directional and if the Auto Submit to VistA Imaging checkbox is selected for the procedure in CP Manager, the study status changes from Pending Instrument Data to Complete after the result has been transmitted to VistA, matched to the study, and copied over to VistA Imaging successfully.  The study is ready for interpretation. At this time, the CP process is complete and attachments cannot be associated with the procedure.

If the instrument is uni-directional or if the instrument is bi-directional and the Auto Submit to VistA Imaging checkbox is not selected, the study status is Ready to Complete.  Go to the next step (9) to manually complete the CP process.

9.	Open the study and add the instrument results and/or external attachments. You can only open studies that have an Error, Complete, Ready to Complete, or New status.  When a study is in the Ready to Complete or New status, you can open the study and finish entering any data that was missed.  An example of missed data is an external attachment that was not associated with the study.

-	Open this study and add results and/or external attachments. Click Open Study or select File > Open Study.

-	Click +Results to select and submit the result to Vista Imaging. Only results for the patient and instrument used for the procedure are displayed. To select multiple results, hold down the CTRL key.  To select a range of results, highlight the initial result, hold down the Shift key, and then click the last result.

-	You can also click +Files to add additional attachments from the External Attachment Directory. If the External Attachment Directory has not been defined for this procedure, the last directory that was accessed may be displayed.  You can browse for other attachments to link to the study.

Note: If the system parameter Allow Non-Instrument Attachments was not selected in CP Manager, +Files does not appear on the Clinical Procedures Study screen, you are not permitted to associate additional attachments with the procedure.

10.	Submit the study. The images are copied to the RAID and the TIU document is created and associated with the Consult order.

11.	Click the magnifying glass under TIU Note to view the TIU Note for that study if it is available. The magnifying glass for the TIU document is unavailable if the result has not been submitted to Vista imaging. Once the result is copied to Vista Imaging, you can view the TIU document of the study before or after the interpretation has been entered.

12.	Click the magnifying glass under Consult to view the Consult report for that study.


Viewing Clinical Procedures Results

You can go to VistA Imaging to view results.  If you as the interpreter did not interpret the result right after the procedure was performed, you may need to view the result before you can enter an interpretation.  Select Tools > VistA Imaging Display.  The patient’s Abstract list is displayed.

1.	Select View > Clinical Procedures to view Clinical Procedures document titles.  The list of CP documents for the patient is displayed.

2.	Click a document title, and then click the camera icon to display the associated images for that CP document.

3.	Double-click the abstract to open the result file.

4.	In the screen where the CP documents are listed, click the CP title, and then click the report icon next to the camera.  The TIU Note is displayed.


Entering the Interpretation into the TIU Note

1.	Logon to CPRS. The Patient Selection screen is displayed.

2.	In the Notifications box at the bottom of the screen, patients are listed with "Procedure ready for interpretation".

- Click Process Info if you want to process a selected item.
- Click Process All if you want to process all of the items listed.
- Click Process Selected if you want to process an item through the Consults tab.

As part of this example, the patient, Clark Kent, is selected.  To view results through Consults, click Process Selected.  The Consults tab is displayed.

Note the image and note document within the Related Documents window.

The consult procedure now has a status of partial results (pr).  The CP document has the TIU note title.

3.	Click the CP title in the Related Documents window.  The CP document is displayed in the right window.

The Author is not defined.  This note is automatically created when the instrument result is sent and submitted and an author does not exist.  The Interpreter who is interpreting the result is the default Author.  The status of the document is always UNDICTATED when the results are ready for interpretation.

4.	To select the results that you want to interpret, choose Action > Consult Results > Complete/Update Results.

Note: To interpret the result, select the Complete/Update Results option.  The Enter Required Fields dialog box is displayed.  The interpreter’s name displays by default in the Author field.

5.	Select the appropriate Procedure Summary Code from the list.

6.	Enter a Procedure Date/Time.  Depending on the instrument, the Procedure Date/Time is passed in the HL7 message from the instrument.  As the interpreter, you can accept the default.  If the instrument does not pass the Procedure Date/Time, the interpreter has to enter a Procedure Date/Time.

The Procedure Summary Code and Procedure Date/Time are required fields for the initial note that you are editing.   The Procedure Summary Codes include Abnormal, Normal, Borderline, and Incomplete.

If you close the Enter Required Fields dialog box, CPRS prompts the interpreter again.

Any subsequent note created after this initial note does not require the Procedure Summary Code and Procedure Date/Time fields.  The fields are optional on subsequent notes.

7.	Enter an interpretation in the space on the right side of the screen for the highlighted (current) consult procedure.


Entering Encounter Information

You can now enter encounter form information.

8.	To enter the encounter information and complete the consult procedure, you must select Action > Consult Results > Sign Note Now.

This window asks if you want to enter encounter information now.  (The Missing Encounter Information window is displayed depending on how CPRS parameters are set. See the Implementation Guide for information on defining CPRS parameters.)

9.	Click Yes to enter encounter information, or click No to skip this step.  If you choose No, you can enter the information at a later time.  In this example, the Yes button is clicked and encounter information is entered.

The Primary Encounter Provider window allows you to verify the primary provider for this encounter form.

10.	Click Yes.

CPRS brings up the Encounter Form that was set up for the Hospital Location, where the procedure was performed.  The Visit Type tab is displayed.

11.	Enter appropriate information for visit type.  For example, in the Visit tab, the following information was entered:

Type of Visit. Established Patient

Section Name. Intermediate Exam 11-19 Min.

Visit Related to Service Connected Condition. Yes

Current providers for this encounter. Gaddie, Marlie

12.	Click the Diagnoses tab.

13.	Enter appropriate information for diagnoses.

14.	Click the Procedures tab.

15.	Enter appropriate procedure information.

16.	Click the Exams tab.

17.	Enter appropriate exam information.  Click OK to return to the Consults tab.


Signing Off

18.	To complete the consult procedure, select Action > Consult Results > Sign Note Now.

19.	Enter your electronic signature to sign the TIU note and complete the consult procedure.

20.	Click OK.

•	The consult procedure now has a status of complete.

•	The hospital location (GI LAB) is used for workload reporting.

•	The workload for the procedure goes through the standard TIU interface with PCE (Patient Care Encounter).

Even though the consult is complete, you can still attach additional files and studies to the same order.


Updating Study Status to Correct Errors

If you open a study in the Error status and have the MD MANAGER key, the Update Study Status window is displayed.  You must have the MD Manager key to access the Update Study Status menu option.  See your clinical application coordinator or IRM for access to Update Study Status.

You can use Update Study Status to change the status of any study.  Be careful when changing the status of a study.  With Update Study Status, you can force a status change of a study if a problem occurs that you cannot fix with the Open a Study option.

1.	Select File > Update Study Status.

2.	Select the status you want to change and click OK.

3.	After you change the status, choose File > Open a Study and click Submit to resubmit the study.


Linking Consent Forms and Images to CP Documents

As the interpreter, you can link a consent form or other images to CP documents by using VistA Imaging Capture. VistA Imaging Capture software can capture clinical images or scanned documents and attach them to Clinical Procedures. Refer to the VistA Imaging 3.0 MAG*3.0*7 Patch Document at the following website:

http://vaww.va.gov/imaging/3.0patches.htm