Health IT Use in VA for the Treatment of Veterans with HIVAIDS Patient Safety and Medical Error Prev

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Health IT Use in VA for the Treatment of
Veterans with HIV/AIDS Patient Safety and
Medical Error Prevention

• Lawrence Deyton, MSPH, MD
• Chief Consultant for
• Public Health Strategic Healthcare Group

Robert M. Kolodner, MD Acting Deputy CIO for
Health Acting Chief Health Informatics Officer
Veterans Health Administration Department of
Veterans Affairs
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Topics for this Session

• Overview of the Department of Veterans Affairs
• Size
• Patient characteristics
• HIV/AIDS
• VistA CPRS VAs Electronic Health Record
  System
• Patient/Population Management IT Tools
• Patient-centric management tools
• View Alerts (Notifications)
• Clinical Reminders
• Disease Registries Population Management tools
• Local
• National
• Backup Slides Patient Safety Initiatives
• Case study with Dyslipidemia

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2004 Who is VA?Veterans Health Administration

• VHA is an Agency of the Department of Veterans
  Affairs (VA)
• Locations Affiliations
• 1,300 Sites-of-Care
• Including
• 158 medical centers,
• 850 clinics, long-term care, domiciliaries,
  home-care programs
• Affiliations with 107 Academic Health Systems
• Additional 25,000 affiliated MDs
• Almost 80,000 trainees each year
• 60 (70 MDs) US health professionals have some
  training in VA

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2004 Who is VA?Veterans Health Administration

• Budget, Staff, Patients
• 193,000 Employees (15,000 Doctors, 56,000
  Nurses, 33,000 AHP)
• 6 decrease since 1995
• 13,000 fewer employees than 1995
• 27.4 Billion budget
• 42 increase since 1995
• Flat at 19B from 1995 - 1999
• 5.1 million patients, 7.5 million enrollees
• 104 increase in patients treated since 1995
• From 2.5 million patients / enrollees in 1995

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Who Are VA Patients ?

• Older
• 49 over age 65
• Sicker
• Compared to Age-Matched Americans
• 3 Additional Non-Mental Health Diagnoses
• 1 Additional Mental Health Diagnosis
• Poorer
• VA health care is a safety net for many
• 70 with annual incomes lt 26,000
• 40 with annual incomes lt 16,000
• 31 without health insurance
• Changing Demographics
• 4.5 female overall
• Females 22.5 of outpatients less than 50 years
  of age

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VA Healthcare System

• Largest single provider in the United States of
  direct care for
• Elderly
• Persons with hepatitis C (180,000)
• Persons with HIV (20,000)
• 70 are minority (non-Caucasian)
• 50 Injection Drug User as risk factor
• 37 with hepatitis C co-infection
• Homeless, etc.

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VA HIV/AIDS Service

• Veterans Benefits and Services Act of 1988 -
  PL 100-322
• VA HIV/AIDS Service charged to implement the
  provisions
• Confidentiality of Medical Records
• Non-discrimination in admission or treatment
  because of HIV
• HIV prevention education and information for
  employees and veterans
• Voluntary HIV testing and consent

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VA and HIV/AIDS Comprehensive Care

• USPHS Guidelines for HIV care - VA standard
• How that care is provided is a local/regional
  decision
• AIDS Coordinator at every VA facility
• All licensed HIV drugs available
• All licensed diagnostics available
• Substance abuse, mental health treatment
  available
• Dental services and case management - infrequent

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Toward a Virtual Health System

• Electronic Health Records (EHRs)
• Robust, Widespread Use of High Performance
  Electronic Health Records (EHRs)
• Personal Health Records (PHRs)
• Full copy of ones own health information along
  with personalized services based on that
  information
• Standards
• Health Data Communication Standards
• Health Information Exchange
• Connectivity Among the EHRs, PHRs, and related
  health entities

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Praise for VistA

• VHAs integrated health information system,
  including its framework for using performance
  measures to improve quality, is considered one of
  the best in the nation.
• Institute of Medicine (IOM) Report,
  Leadership by Example Coordinating Government
  Roles in Improving Health Care Quality (2002)

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Success In Supporting Health Care Delivery For
Millions Of Veterans

• National software w/ local flexibility/innovation
  
• Innovation developed locally enterprise wide
• Standard packages distributed enterprise wide,
  e.g. latest version of CPRS
• Single longitudinal health record is immediately
  available in inpatient, outpatient, and long-term
  care settings
• Initial system (1983-1996) was built around dumb
  terminals
• Applications separated out by Hospital/Clinic
  Service
• Simple roll-and-scroll screens

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In 1996, VA launched the Computerized Patient
Record System -- CPRS-- a comprehensive,
integrated Electronic Health Record (EHR)
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Electronic Health Records (EHR) Computerized
Provider Order Entry (CPOE)

• 100 VA Medical Centers have Electronic Health
  Record
• CPOE is one of the Leapfrog Groups Top 3
  Safety Strategies
• Outside of VA, CPOE lt 8 nationally
• lt 30 among Academic Medical Centers
• Nationally, 93 of all VA Rxs by CPOE
• Ultimate Goal 100
• VA is the Benchmark for CPOE
• All Medical Centers also have Desktop Imaging

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And VistA Is Actively Used... Some National
VistA Statistics (Total / Daily)

• Number of Documents (Progress Notes, Discharge
  Summaries, Reports)
• 533,000,000 / gt510,000
• Number of orders
• 1.14 Billion / gt860,000
• Number of Images
• 197,000,000 / 340,000

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Patient/Population Management IT Tools
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System Tools for Patient/Population Management

• View Alerts (Notifications)
• Clinical Reminders
• Disease Registries
• Local National Capabilities

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CPRS View Alerts
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Clinical Reminders
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Clinical Reminders Supporting the Clinical
Workflow

• Contemporary Expression of Practice Guidelines
• Time Context Sensitive
• Reduce Negative Variation
• Create Standard Data
• Acquire health data beyond care delivered in VA

Links Reminder
With the Action
With Documentation
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HIV Clinical Reminders in CPRS

• T cell counts and Viral Load (VL)
• Have they been done?
• PCP and MAC prophylaxis
• Indicated, and if so, is patient on recommended
  meds?
• Initiation of antiretroviral (ARV) therapy
• Kaiser Family Foundation / DHHS guidelines
• Lipid Management
• Have they been done?
• Above a threshold?

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National ICR Database
National Immunology Case Registry (ICR) Database
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Local Registry System Immunology Case Registry
(ICR)

• Managed by Clinicians at each facility
• Automatic Patient identification
• ICD-9
• Laboratory test results HIV
• Customizable reports using existing local data
• Population Management
• Export capabilities

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National ICR DatabaseDemographic and Clinical
Data

• Patient Demographics
• All Lab Results (selected subset of Lab Tests)
• Microbiology Results
• Surgical Pathology/Cytopathology Reports
• Outpatient and Inpatient (Unit Dose IV)
  medications
• Admissions (NPC)
• Outpatient Visits (NPC)
• Radiology Reports
• Allergies
• Vitals

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Clinical Data Elements

• For all clinical orders we know
• Who Ordered it
• Provider Class, Provider-site number
• Where it was done
• Station, substation, Community-Based Outpatient
  Clinics (CBOC), Send out
• What were the Results

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National Data Merge

• Although we are One VA, our data reflects 128
  independent, University associated,
  multidisciplinary teaching institutions all
  trying to do it their way while we try and
  merge it into One VA

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Benefits of a National Database for HIV/AIDS
Patients

• National Database
• Supports characterization of known or unknown
  toxicities
• Supports querying against standards (e.g.
  guidelines)
• Allows identification of areas where improvements
  can be made
• Provides means to monitor impact of interventions

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VA Patient Safety Program

• Local Electronic Health Record (VistA) supports
• Checks to limit risk
• Drug Ordering and Administration
• Patient Centric interventions
• Clinical Reminders
• Local Population Management (HIV registry)
• New problems
• Identify patients at risk

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• Questions and Discussion

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• Backup SlideA Patient Safety Case Study

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Patient Safety Initiative Case Study

• Dyslipidemia
• Are we screening for it?
• When we identify a problem do we treat it?
• If we treat it pharmacologically, are we using
  appropriate (safe) medications?
• Are toxicities related to anti-lipemic use being
  observed?

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Are we screening for it? (National Data)
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Dyslipidemia Monitoring

• We could do better
• Education program to include
• Clinical reminder to check lipids
• Instruction on how to use local reports to
  monitor population
• Outcomes data on what happens to lipid levels
  post initiation of ARVs
• Do Clinicians believe that there is a problem?

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Dyslipidemia When we identify a problem, do we
manage it?
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Managing Dyslipidemia - Interventions

• Provide clinicians with tools to
• Catch high lipid levels at time of visit
• Monitor local population for
• Patients with high levels
• Patients at risk (high baseline lipids starting
  ARVs)

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Are We Using Appropriate (safe) Medications?
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Interventions

• Dissemination of new information to HIV
  clinicians
• Collaboration with VA formulary leadership
• Appropriate medications for population (statin)
• Drug interaction software to catch high risk
  combinations when co-prescribed

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Are toxicities secondary to anti-lipemic use
being observed?

• Myositis, myalgias, liver enzyme elevations and
  elevated CPK
• May be caused by other etiologies including HIV,
  ARVs
• Rhabdomyolysis
• Seen at low frequency with statin use
• Is risk higher with PI/DLV drug interaction?

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Identification of Rhabdomyolysis in HIV VA
Patients
ICD-9 code for Rhabdomyolysis
25,417 HIV patients
142 patients

• No electronic medical charts available for review
• 2. CPK lt 1500
• 3. No diagnosis of Rhabdomyolysis in notes

73 Excluded
gt 1,500 exposures to Statin PI/DLV
69 patients
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Primary Etiology for Rhabdomyolysis in HIV VA
Patients
N 69
Seizure
Other
Trauma
Unknown
Substance Abuse
Medication Induced
6 of 15 due to statin medications