CVR TOOL – USER GUIDE
Contents
1. Some interventions only have adverse effects where the risk is too uncommon to be depicted with the 100 smileys graphic In these cases the Adverse Effects tabs will have no coloured faces just 100 yellow smiling faces but the Adverse Effect Details hyperlink will still be present containing a link to the description box An example of this 1s shown here for smoking cessation r CV Decide QRISK Patient Details Calculator Adverse Effect Details gu Adverse Effect Details Possible Adverse Effects People who quit smoking will gain on average 2 6kg 5 Ibs for women and 5 1kg 11 2Ibs for men in the first five years After five years this difference falls to 1 8kg 4 Ibs for women and 2 9kg 6 4Ibs for men 15 7 Producing a Patient Print Out The next stage is to summarise the consultation and produce a printout to give to a patient to take home after the consultation ends Once you have finished going through the relevant intervention and adverse effect details with your patient click the Summary Screen button at the bottom of the Patient Details screen a CV Decide QRISK Patient Details Calculator Ron Number Atrial Fibrillation F Type 2 Diabetes Renal Disease F Ethnic Origin British v Step 1 Estimating your risk of cardiovascular disease Age 68 Sex M D 0 B 03 04 1944 Last Cardiovasc2. smoking Cessation advice 8CAL Clicking the OK button at the bottom of this screen will end the CVDecide consultation The only part of CVDecide left running will be the Welcome Screen ready for another patient Important note At this point the following items will have been filed in EMIS Please see Items filed for further information e The patient s cardiovascular risk score e A note indicating that CVDecide was used a list of all items discussed and a list of all items agreed e Any additional READ coded items that were agreed e g Referral to Stop Smoking Clinic If you believe any of these were filed in error e g by you clicking an incorrect option in CVDecide this must be amended directly in your EMIS client with an appropriate explanatory note and not through CVDecide 9 Shutting CVDecide down Entering EX into the Welcome screen or clicking Exit onthe Welcome screen or clicking the cross in the top right hand corner of the Welcome screen will shut CVDecide down You will need to launch it again from scratch including logging in the next time you come to use t 10 Items filed At the end of each consultation using QRISK2 the following items will always be filed READ Code 38B1 Vascular risk assessment with a note indicating CV Decide was used READ Code 38DP QRISK2 10 year risk score with a note listing all discussed and agreed items as they appear on the CVDecide Patient Pr
3. patients like the one in front of you A proportion are coloured red and sport a sad expression reflecting the number of patients like this one that will suffer a CVD event in the next ten years The risk is also shown numerically below the faces and ona Sliding scale bar with the risk highlighted in red randomly distributed To emphasise the unpredictability of CVD you can return to the Patient Details screen click the Patient Details tab above the faces and click Calculate again This time the faces will be differently distributed If you wish to print out the calculator screen so that a patient can take a print out home there is a Print button in the bottom right hand corner Note If the patient does not have a recognised North East postcode or there is no postcode entered for that patient you will receive a message notifying you that the Townsend deprivation score is not being used in any of the calculations However you will still be able to use CVDecide as normal but without this parameter being used in the risk calculations 5 Selecting interventions When you are ready to discuss interventions with the patient click the Patient Details tab above the faces You will be returned to the Patient Details screen Step 2 What can we do to reduce your risk The interventions are grouped into two categories First interventions that have a risk reduction associated with them in CVDecide These cons
4. them Patient Details Calculator Calcium Channel Blockers Adverse Effects Consultation Summary Screen This is what we have talked about Stopping Smoking V We have agreed this action Smoking Cessation advice 8CAL Additional Infomation Calcium Channel Blockers W We have agreed this action Advice Given v Additional Information Target blood pressure 140 We have agreed this action Advice Given X Additional Information Continue to Print Screen Note for interventions involving BMI d et exercise and smoking cessation where READ codes are available corresponding to the local Health Checks SOP a READ code is included You will be able to file these READ codes in the patient s EMIS record at the end of the consultation In the example given two options have been greed The patient will attempt to stop smoking and has been given advice The patient will take medication Caltium Channel Blockers to achieve a target systolic blood pressure of 140 mghMg Once you are happy that you have selected the orrect items click the Continue to Print Screen button at the bottom of the page 17 You will then be presented with the Patient Printout screen CV Decide QRISK Patient Details Calculator Calcium Channel Blockers Adverse Effects Consultation Summary Screen Patient Printout CV Decide 09 12 2012 About You Ron Number Of 100 people with the same r
5. CVDecide QRISK2 User Guide Contents 1 Belore VOU Stai aaen a E E S dacdaaueacneacnaes l 2 Openme CV Decide and LOSSE IN siene eel aeeiita eee liaena l a Caleulating the baseine TSK sii sssstidactasiuateadad aniaesteiauarencsat iasiemeatonaveedacahdensen 6 Di DClCCUNG ANLer Ve MLO NS wasictisiswareceiacidniwe leh E 8 6 The adverse effects OT interventions x iis cnceeoseseadccsas canes seinccswoneneddsetivadincennonsdueeeiaces 10 T Producing a Patient Print Out sicces5sccstrees cttien veicachardeutawsiceetaxseenesuesoedaueeieiauvednaaets 16 Se Savne TANIA COSINE arenasi a E EEE 19 9 gt shuttme C VDecide GOW mesne N a a a a 20 VO cle mis od eari E E E E S 20 1 Before you start Ensure that EMIS is running on your desktop and you are logged in Before you view a patient s details please make sure that the desired patient has been selected in EMIS Note If you have multiple instances of EMIS open on your computer C VDecide is not able to identify the correct patient and will not launch You should therefore only have one EMIS window open and running on your computer before launching CVDecide 2 Opening CVDecide and Logging in When you launch CVDecide it will attempt to automatically log in to EMIS for you If this is successful you will receive a message informing you of this Clicking the OK box underneath this message will then take you straight to the CVDecide Welcome screen E al Welcome to CV
6. Decide i 2 Sa CVDecide Please use only 1 instance of EMIS open at the desired patient record RC QRISK2 Risk Calculator FR Calibrated Framingham Risk Calculator Note Before choosing this option you are advised to read the information shown here EX Exit LF Choose Log File Select option Note By selecting either Risk Calculator you are accepting the terms and conditions stated here _ If the automatic logon does not work you will be presented with both the Welcome screen and a separate Login screen as is shown below Login ID Password OK Exit ha pE EMIS LV For UPSR Windows Calibrated Framingham Risk Calculator ra ES Note Before choosing this option you are advised to read the information shown here LV Client Backupslid Shortcut EX Exit LF Choose Log File MES McAfee EmisWeb exe Security Sc Shortcut a Welcome to CVDecide CVDecide You are not logged in QRISK2 Risk Calculator Select option Note By selecting either Risk Calculator you are accepting the terms and conditions stated here Zg Z My Club Google oi T VAIO Chrome 3 eat Go to the Login screen click the Username box and type in your EMIS username Then click the password box and enter your EMIS password Note these login details are passed directly to your EMIS server which means the password is case sensitive Finally click the OK button
7. W Decide ORIS AE Please complete this additional information O Cardiovascular disease C Prescribed Corticosteroids Smoking Category Moderate 10 19 cigarettes per day ka Two tick boxes need to be checked e if the patient has cardiovascular disease e if they are taking steroids The third value requires a smoking category to be selected from a drop down list or confirmed as smoking category was needed for the QRISK2 equation and the smoking category selected should already be the default option in the Smoking Category box for QStatins too Once you have completed this additional information click the Confirm button in the centre of the screen At this point a new tab will appear entitled Statins Adverse Effects though as above the tool returns to the Patient Details screen and the process continues as for all other interventions 12 Adverse effects screen When you click an adverse effects tab you will be taken to an Adverse Effects screen Adverse effects of 1 in 100 or above are illustrated on this screen using the smiley face graphic The faces have different colours to represent each effect A colour key is displayed underneath the faces E CV_Decide ORSK Nausea 24 in 100 insomnia in 100 Adverse Effect Details S Abnormal Dreams 10 in 100 F To give the patient more information a lue underlined link will also be present underneath the faces at th
8. ardiovascular Risk Score 43 Ethnic Origin British X BMI 232 Postcode Y0407BR Systolic BP 190 mmHG Cholesterol HDL Ratio 4 Please complete this section Atrial Fibrillation F Smoker f7 Smoking Category Moderate 10 19 cigarettes per day v Type 2 Diabetes v Blood Pressure Treated Yes X Renal Disease F i iti E Cholesterol Treated No Stop Smoking Healthy Diet Moderate Walking C Aspirin Target Cholesterol Ratio Target Systolic Blqbd Pressure Target BMI Calculat Treatments Discussed Hypertension Lipid Lowering Smoking Calcium Channel Blockers F Statins NRT E Thiazide Diuretics F Bupropion E ACE F Varenicline ARB N Summary Screen Beta Blockers M If there is any information missing from the details you will be shown an error message and given the opportunity to re check the Patient Details screen Otherwise you will be shown the Calculator screen Note Once you have pressed calculate button the patient details cannot be edited unless you close the tool for this patient and re open For the evidence underpinning the risk calculation please see the Evidence Summary available as a link from the CVDecide web page The Calculator Screen CV Decide QRISK Patient Details Calculator 10 year CVD Risk About 47 in 100 people L g The calculator screen contains 100 faces which represent 100
9. at the bottom of the Login screen If you make a mistake whilst entering your login details you will be given the opportunity to re enter them into the Login screen However if the details are correct the Login screen will disappear and leave you with the Welcome screen displayed on your computer You can use either QRISK2 or Framingham risk calculator this user guide is for QRISK2 Important By opening the risk calculator you are agreeing to the terms and conditions accessible from the Welcome Screen You must read through these before you use the tool for the first time To do so click the hyperlink at the bottom of the Welcome Screen a Welcome to CVDecide CVDecide Please use only 1 instance of EMIS o en at the desired patient record RC QRISK2 Risk Calculator FR Calibrated Framingham Risk Calculator Note Before choosing this option you are advised to read the infoqnation shown here EX Exit LF Choose Log File Select option Note By selecting either Risk Calculator you are accepting the terms and conditions stated here The tool is now ready for consultation with a patient The choose log File option 1s not needed for routine use 3 Using CVDecide during a consultation First you will see the CVDecide Patient Details screen below F Step 1 Estimating your risk of cardiovascular disease This section shows the patient details ob
10. ate Step 2 What we can do to reduce your risk Please select only one intervention at a time Stop Smoking Healthy Diet Minimal Walking Moderate Walking Aspirin Target Cholesterol Ratio Target Systolic Blood Pressure Target BMI Calculate Treatments Discussed Hypertension Lipid Lowering Smoking Calcium Channel Blockers Statins E NRT Thiazide Diuretics F Bupropion ACE Varenicline ARB O Summary Screen Beta Blockers Important There is an Allergy details hyperlink which will only be displayed if there are any allergies recorded in EMIS for this patient If as in the examples shown in this user guide this hyperlink is not visible towards the bottom of the screen there are no allergies noted in EMIS for this patient Once you have checked that CV Decide is showing information for the correct patient you can start using the tool Note Any piece of text coloured blue and underlined is a hyperlink to further information For example the hyperlink under the name of each intervention gives a brief definition of each intervention which you could show to the patient if you wish 4 Cakulating the baseline risk When you are ready to calculate the patient s initial risk click either of the Calculate buttons on the Patient Details screen a CV Decide QRISK Patient Details Calculator Step 1 Estimating your ris rdiovascular disease Ron Number Age 68 Sex M D B 703 04 1944 Last C
11. culator Statins Adverse Effects Step 1 Estimating your risk of cardiovascular disease Ron Number Age 68 Sex M D O B 03 04 1944 Last Cardiovascular Risk Score 43 Ethnic Origin British gt BM 232 Postcode YO407BR Systolic BP 190 mmHG Cholesterol HDL Ratio 4 Please complete this section Atrial Fibrillation F Smoker v Smoking Category Moderate 10 19 cigarettes per day Type 2 Diabetes Family History of Premature CVD M Blood Pressure Treated Yes Renal Disease T Rheumatoid Arthritis F Cholesterol Treated No Calculate Step 2 What we can do to reduce your risk Please select only one intervention at a time Stop Smoking Healthy Diet Minimal Walking Moderate Walking Aspirin E Target Cholesterol Ratio Target Systolic Blood Pressure Target BMI Calculate Treg Discussed Hypertension Lipid Lowering Smoking Calcium Channel Blockers F Statins W NRT E Thiazide Diuretics F Bupropion ACE IF Varenicline F Beta Blockers Ext CV Decide Note checking the box for Statins also opens a separate tab but additional input 1s required CVDecide uses the QStatins risk equation and illustrates the adverse effects of Statins personalised to each patient QStatins requires additional input values Therefore you will be shown a screen requesting input of further mformation 11 Y
12. e bottom right entitled Adverse Effect Details Clicking on this link produces a box describing the adverse effects Importantly this box will also describe any adverse effects whose chance of occurrence is less than 1 in 100 and which therefore cannot be easily shown via the 100 faces 13 For example ACE inhibitors have adverse effects that can be shown with the smileys graphic and adverse effects that are less common CV Decide QRISK Patient Details Calculator ACE Inhibitors Adverse Effects Cough 4 in 100 Adverse Effect Details Adverse Effect Details io B x4 en ee ll Possible Adverse Effects Between 1 and 2 people in every 1000 will develop angioedema presence of large amounts of fluid in certain tissues under the skin leading to swelling and large wheals as a result of taking ACE inhibitors to reduce their blood pressure About 4 in every 100 people will experience a dry cough as a result of taking ACE inhibitors to reduce their blood pressure Clicking the OK button at the bottom will hide the box again Once you have finished looking at the adverse effects click the Patient Details tab to return to the Patient Details screen You do not need to close the adverse effects tab at this point whenever you uncheck an intervention s tick box the adverse effects tab for that intervention will disappear automatically 14 Important
13. ed For the evidence underpinning the risk reduction recalculation please see the Evidence Summary available asa link from the CVDecide web page 6 The adverse effects of interventions CVDecide lets you illustrate the risk of adverse effects of interventions Some interventions as noted above in Section 5 are connected directly with adverse effects and a new tab is automatically opened when these interventions are selected as previously stated For the evidence underpinning the adverse effects data please see the Evidence Summary available as a link from the CVDecide web page Other medical treatments which could be discussed in a consultation are listed towards the bottom of the screen and you are able to discuss the adverse effects of these medications with your patients Treatments Discussed Hypertension Lipid Lowering Smoking Calcium Channel Blockers Statins NRT Thiazide Diuretics Bupropion ACE Varenicline ARB Summary Screen Beta Blockers Whenever you check the tick box relating to one of these medications with the exception of Statins see below a new tab will appear at the top of the screen with the name of the medication and Adverse Effects for example Calcium Channel Blockers Adverse Effects CVDecide will remain on the Patient Details screen and it is up to you when to click on the adverse effects tab 10 Statins CV Decide QRISK a eee Patient Details Cal
14. interventions have adverse effects associated with them a new tab will be opened describing those adverse effects However you will not be taken automatically to this tab you will need to click on it in order to view it Please see Section 6 of this guide for more information on adverse effect tabs and the information they display Once you have selected an intervention or interventions click the Calculate button again The Calculator screen will be shown with three important changes E CV Decide QRISK Patient Details Calculator Smoking Cessation Adverse Effects i i if i d i 1 am I i i 1 EEGGE GREER PERE EEEGE EEEEE 10 year CVD Risk About 47 in 100 people D om With Stopping Smoking About 39 in 100 people First the faces will be grouped together to show the new reduced risk of CVD emphasising the reduction with white faces Second the sliding scale bar under the faces will now also show the reduced risk Third the new CVD risk will be displayed numerically under the bar You are still able to print the faces screen at any time by clicking the Print button in the bottom right hand corner This process of returning to the Patient Details screen selecting an intervention or interventions and then clicking Calculate to show the effect of an intervention may be repeated as often as requir
15. intout screen 20 These discussed and agreed items will be one or more of the following Stopping smoking healthy diet minimal walking moderate walking target cholesterol ratio target systolic blood pressure target BMI Aspirin Statins ACE inhibitors ARB calcium channel blockers beta blockers NRT Buproprion and Varenicline If targets are agreed for one or more of blood pressure cholesterol or BMI the chosen target value will also be noted The following items will be filed only if they are agreed outcomes of the consultation READ Code 8CA4 Advised re diet READ Code 8HHH Referral to weight management programme READ Code 679P Health Education Weight Management READ Code 8CAL Smoking Cessation advice READ Code 8HTK Referral to stop smoking clinic READ Code 8CAS Patients advise re exercise READ Code 8HHc Referred for exercise programme READ Code 8B6A Statins Prophylaxis 21
16. isk factors as you 47 would have a cardiovascular event within the next 10 years BMI 232 Systolic Blood Pressure 190 mm HG Blood Pressure Treated Yes v Cholesterol HDL Ratio 4 Cholesterol Treated No X V Smoker We talked about Blood Pressure Medication We agreed Stopping Smoking Smoking Cessation advice Calcium Channel Blockers Advice Given Target blood pressure 140 Advice Given These interventions combined reduce your risk to about 34 in 100 people Save and Close At the top of the page are the patient s personal details taken from the Patient Details screen In the centre is a brief list of the items talked about during the consultation Finally the rest of the page contains a list of all items discussed and actions agreed during the consultation READ codes are not listed on the patient printout You are advised to check that the details are correct before printing To print out the information on this page simply click the Print button at the very bottom of the screen On clicking the Print button you will be presented with a Print information box Note The Print information box that appears is identical to the information box you see when you print a Word document in Microsoft Office Therefore the exact configuration settings you need for this will depend on your practice s printer You are advised to print the page in landscape format The process for printing out
17. ist of check boxes for lifestyle interventions plus aspirin and numerical boxes for Target Systolic Blood Pressure Target Cholesterol Ratio and Target BMI Simply select the interventions for discussion one at a time by either ticking the box or in the case of the target boxes entering a new target value into the box Second Treatments Discussed medications check boxes allow you to illustrate the adverse effects of medications and not do not show risk reductions for example risk reduction for lowered blood pressure will be enacted through entering a target BP not through selection of an anti hypertensive medication Step 2 What we can do to reduce your risk Please select only one intervention at a time Stop Smoking Healthy Diet Minimal Walking Moderate Walking Aspirin Target Cholesterol Ratio Target Systolic Blood Pressure Target BMI Calculate Treatments Discussed Hypertension Lipid Lowering Smoking Calcium Channel Blockers Statins NRT Thiazide Diuretics Bupropion ACE Varenicline ARB Summary Screen Beta Blockers Note The target boxes are designed to accept the new target value not the amount you would like that value to be reduced by For example if your patient had a systolic blood pressure of 170 and you wanted to show the reduced risk that a blood pressure of 140 would have you should enter 140 in the Target Systolic Blood Pressure box Note If any of the selected
18. tained from the EMIS medical record Where there is no EMIS data available the field will be left blank You can to enter new values for any of the baselne details and check or uncheck any of the tick boxes in this section CVDecide simply scans information from the EMIS medical record and does NOT check this information Please complete this section BP Treated Cholesterol Treated and Smoking Category do not obtain information from EMIS Your selections from the drop down lists are needed to complete this section Important The patient s name age date of birth sex and postcode will be displayed at the top of the Patient Details screen Check before continuing that this is the correct patient If it is not the correct patient check that you have the correct patient s medical record open in EMIS and that you do not have multiple instances of EMIS open at the same time CV Decide QRISK Patient Details Calculat Step 1 Estimating your risk of cardiovascular disease Ron Number Age 68 Sex M D 0 B 03 04 1944 Last Cardiovascular Risk Score 43 Ethnic Origin British x BMI 232 Postcode Y0407BR Systolic BP 190 mm HG Cholesterol HDL Ratio 4 Please complete this section Atrial Fibrillation F Smoker Smoking Category lt Select gt m Type 2 Diabetes Family History of Premature CVD W Blood Pressure Treated lt Select gt v Renal Disease Rheumatoid Arthritis Cholesterol Treated lt Select gt v Calcul
19. the smiley faces works in the same manner 18 8 Saving and closing At the end of the consultation you need to close down the Patient Printout screen To do so click the Save and close button at the bottom of the screen CV Decide QRISK Patient Details Calculator Calcium Channel Blockers Adverse Effects Consultation Summary Screen Patient Printout CV Decide 09 12 2012 About You Ron Number Of 100 people with the same risk factors as you 47 would have a cardiovascular event withingfhe next 10 years BMI 232 Systolic Blood Pressure 190 mm HG Blood Pressure Treat d Yes v Cholesterol HDL Ratio 4 Cholesterol Treated No X V Smoker We talked about Blood Pressure Medication We agreed Stopping Smoking Smoking Cessation advice Calcium Channel Blockers Advice Given Target blood pressure 140 Advice Given These interventions combined reduce your risk to about 34 in 100 people You will receive a summary of all items filed into EMIS In addition a note will also be filed indicating that you have used C VDecide Further information on this is given below Where agreed actions do not have associated READ codes brief text about the action is recorded in the medical record 19 at Notification el as You have now written the following risk score to the EMIS medical record 4 7 You have now written the following additional items to the EMIS medical record
20. ular Risk Score 43 BMI 232 Postcode Y0407BR Systolic BP 19 mmHG Cholesterol HDL Ratio 4 yiease complete this section Smoker v Smoking Cftegory Moderate 10 19 cigarettes per day Family History of Premature CVD V Blood Prgssure Treated Yes Rheumatoid Arthritis F Choles rol Treated No X Calculate Step 2 What we can do to reduce four risk Please select only one interventiof at a time Stop Smoking F Healthy Diet F Minimal Walking E Moderate Walking F Aspirin C Target Cholesterol Ratio Target Systolic Blood Presgure Target BMI Calculate Treatments Disg gt C Hypertension Lipid Lowering Smoking Calcium Channel Blockers E Statins E NRI E Thiazide Diuretics Bupropion O ACE Varenicline ARB Summary Screen Beta Blockers This will transfer you to a new screen entitled Consultation Summary Screen 16 Consultation summary screen The Consultation Summary Screen lists all the items that you have talked about during the consultation The next stage is for you and your patient to agree on what actions to take next Important Once you have agreed which actions the patient will take you should tick the Agreed box for each intervention and complete the drop down box underneath each intervention You can also add free text in the adjacent Additional Information boxes Please note that this text will then appear in the printout that the patient gets to take away with
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