Health Tech Net July 15, 2005

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Health Tech Net July 15, 2005

• 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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VistA Supports VHA

• 196,500 Employees
• 15,000 Physicians
• 56,000 Nurses
• 33,000 Allied Health Professionals
• PLUS
• Affiliations with 107 Academic Health Systems
• Additional 25,000 affiliated Physicians
• Almost 80,000 trainees each year
• 1300 Sites-of-Care
• Including 157 medical centers, 850 clinics,
  long-term care, domiciliaries, home-care programs

Source QTR Exec Summary Mar 2005
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VistAs Cost

• VA runs 128 VistA systems these sites
• Down from 172 VistA systems 10 years ago
• 180,000 PCs and thin clients
• For FY2004
• Cost per enrollee
• 78 / enrollee
• Average cost per hospital (n158)
• 3.6 million
• Delivers a complete hospital information system,
  electronic health record, imaging, BCMA
• Hardware, software, maintenance, upgrades,
  staffing

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

• Documents (Progress Notes, Discharge Summaries,
  Reports)
• 698,000,000.. 567,000 each workday
• Orders
• 1.4 Billion. ... 931,000 each workday
• Images
• 338,000,000 534,000 each workday
• Vital Sign Measurements
• 863,000,000 676,000 each workday
• Medications Administeredwith the Bar Code
  Medication Administration (BCMA) system
• 670,000,000 616,000 each workday

Statistics as of June 2005
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Medical Computing Status

• . . . Given the huge increase in
  personal computer and Internet use, as well as
  the dramatic changes in other industries, most
  consumers assume that healthcare is highly
  electronic and computerized. The reality,
  however, is that 90 percent of the business of
  healthcare remains paper-based. Why?

Rx 2000 Institute http//www.rx2000.org/KnowledgeC
enter/hipaa/elearning/QC_govt.htm
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Except in VA !
Every VA Medical Center has Electronic Health
Records !
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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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(Still More) Quotes About VistA . . .

• nowhere is the VA outrunning the private
  healthcare sector by a wider margin than in the
  adoption of clinical information technology.
• Modern Physician, August 1, 2003
• The Electronic Health Record in the Department
  of Veterans Affairs is the best in the United
  States, absolutely the best at large scale, and
  probably the best in the world.
• John Glaser, Ph.D., October 2003Vice President
  CIOPartners (Harvard) HealthCare System

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However

• This is NOT about technology
• It is about RESULTS
• Improved Health Care Quality
• Improved Health Outcomes

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And in January 2005
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Performance MeasurementSetting the U.S.
Benchmark for 18 Comparable Indicators
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Highest Quality of Care For Patients in VA
Measured Broadly

• Patients from the VHA received higher-quality
  care according to a broad measure. Differences
  were greatest in areas where the VHA has
  established performance measures and actively
  monitors performance.
• Annals of Internal Medicine, December 21, 2004

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Agenda
Current VistA HealtheVet-VistA HealthePeople-V
istA
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Past and Present
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Success In Supporting Health Care Delivery For
Millions Of Veterans

• VistA is a success
• Built by fire of VHA collaboration
• Publicly owned by VA plan to remain so for the
  next generation system
• Strong interest by public/private in using VistA
• National software w/ local flexibility/innovation
  
• Began as a system in each of the 172 major VA
  facilities
• Innovation developed locally enterprise wide
• Standard packages distributed enterprise wide,
  e.g. latest version of CPRS

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VistA Features

• Renamed DHCP to VistA w/ the launch of CPRS
• Veterans Health Information Systems and
  Technology Architecture
• 100 separate business packages that support
  day-to-day activities of healthcare operations,
  including
• Provider systems
• Registration/enrollment/eligibility
• Management and financial systems

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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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VistAs Contribution to VA

• Creating a Culture of Quality The Remarkable
  Transformation of the Department of Veterans
  Affairs Health Care System
• What was largely an inpatient,
  subspecialty-based system became a
  full-service, integrated delivery system
  committed to a new model of health promotion,
  disease prevention, and coordination of care.
• The culture of quality depended on the
  successful implementation of several innovations
  a uniform data collection system facilitated by
  nationwide implementation of an electronic
  medical record system, systematic application of
  quality standards, and externally monitored local
  area networks to monitor quality.
• Annals of Internal Medicine, Editorial, August
  17, 2004

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Electronic Health Records Computerized Provider
Order Entry

• Computerized Provider Order Entry (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, 94 of all VA prescriptions are
  entered directly by providers
• Ultimate Goal 100
• VA is the Benchmark for CPOE

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Clinical Reminders
Links Reminder

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

With the Action
With Documentation
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Morphing from VistA to HealtheVet-VistA

• What has happened in the past year?
• Data Standardization progressing in first few
  domains
• Health Data Repository - HDR (version 1) - ready
  for initial deployment
• Launching pilots to implement Regional Data
  Processing Centers to replace facility-based
  system distribution
• Last CPRS (in Delphi) Version 26 due out in
  October
• CPRS-R getting ready for testing
• Administrative Data Repository (ADR) concept
  developed and being pursued
• Investing in Common Services and initial
  Rehosting
• Pharmacy re-engineering restructured to deliver
  in 2008
• Laboratory re-engineering getting underway this
  year
• Scheduling alpha test delayed until Fall 2005
• My HealtheVet steadily adding new capabilities

142 Latest CPRS GUI Enhancements
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The Future
Next Generation VistA..
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VistA - Why change?

• Not lose functionality we have
• Strengthen VistA
• Move to person data focus
• Move to standardized, fully sharable health data
• Approximately 30 of veterans receive care at two
  or more VHA facilities.
• An estimated 40 of veterans we treat receive
  care outside of VHA
• Increase system availability and reliability
• Increase flexibility to respond to future health
  needs
• Lower cost of maintenance
• Modernize replace older systems
• Ensure documentation on application programs
• Move to modern technologies

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Operational (Clinical) Drivers for Change

• Support our future health system
• Maximize
• Health/wellness/abilities
• Satisfaction
• Quality
• Accessibility/portability of care
• Affordability to taxpayer and Veteran
• Patient safety (defects/errors to zero)
• Security and privacy
• Minimize (for the Veteran)
• Time between disability/illness maximized
  function/health (time to zero)
• Inconvenience (inconvenience to zero)

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What is HealtheVet-VistA?

• HealtheVet-VistA
• is the REPLACEMENT of the existing VistA system
  by rehosting, enhancing, and/or reengineering
  current health information applications to
  process on a new technology platform
• Hardware and services
• will be redundant (a good thing) and COOPed
  Continuity of Operations
• Modernization effort includes
• Systems Platform
• Software Design
• Development Methodology

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HealtheVet Strategy Overview

• Built on VistA /CPRS foundation
• Minimizes change for the health care providers
• Built collaboratively
• by VHA field/CO leadership staff and with the
  Department
• Existing components of the current VistA system
  will be retired incrementally
• as HealtheVet-VistA is deployed in stages
• Will eventually replace all VistA software
• Migratory/evolutionary process as risk mitigation
• Morphing from VistA to HealtheVet-VistA
• Remains publicly owned

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Health Data Repository (HDR) A Step Towards
HealtheVet-VistA

• The data layer
• A central repository of person-centered clinical
  health information
• for use by clinicians and other personnel in
  support of patient-centric care 
• supports clinical decision-making for better
  quality, safer patient care, independent of where
  the patient information was first entered
• Health Data Repository (HDR)
• Domain-by-domain filling of the national HDR as
  local VistA data is cleaned to align with new
  standards
• Start with Allergies, Outpatient Pharmacy, Vital
  Signs, Laboratory Results by the end of July 2005
• Standardized (and computable) data from all VHA
  sites
• VHA will make a Quantum Leap as VHA-wide
  database integration becomes operational

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This is an actual patient who has been seen in 36
different VA medical centers in the past 10
years. Allergy reactants were recorded
differently in Cheyenne and St. Louis (and
probably in many other sites). For example,
Vistaril and Hydroxyzine are the same
drug. Decision support will be strengthened when
allergy reactants are standardized.
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HDR The Benefits

• Health Data Repository (HDR)
• Becomes the source for non-local data once the
  domain is turned on
• Feeds a clinical data warehouse for further
  analyses research (with appropriate privacy
  controls)
• Fall 2005 - Drug/Allergy and Drug/Drug
  Interactions across VHA
• Increases patient safety across VHA
• Will exchange pharmacy allergy information with
  DoD for patients receiving health care in both
  systems
• Provides real-time interaction detection for both
  VA DoD data

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HDR Some Content

• Health Data Repository (HDR) First 12 of 34
  Domains
• Demographics
• Pharmacy
• Allergies/Adverse Reactions
• Vitals
• Laboratory
• Problem List
• Text Documents (Text Integration Utilities /
  Notes)
• Orders
• Encounters
• Health Factors (support the clinical reminders
  capabilities)
• Radiology
• Immunizations

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HDR How Is It Different Than Current State?

• Current State
• Facility-centric
• Data is not standardized from site to site,
  therefore it is not computable
• Automated Clinical Decision Support uses data
  only from the local VistA system (1 of 128)

• Future State
• Patient-centric (Veteran-centric)
• Standardization of data becomes the foundation
  for decision support functionality
• Automated Clinical Decision Support is available
  in real time across all sites of care

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Personal Health Records
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Principles
My HealtheVet (Phase 1) Veterans Day 2003

• The veteran "owns" his/her My HealtheVet Personal
  Health Record
• The VistA Computerized Patient Record System
  (CPRS) is the authoritative VA medical record
• The veteran can request that a copy of his/her
  VistA record be electronically extracted and sent
  to the My HealtheVet system

www.myhealth.va.gov
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My HealtheVet
My HealtheVet is a new ehealth portal where
veterans, family, and clinicians may come
together to optimize veterans health care.
Whats Coming
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To be (VA Beyond)
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Progress Toward US Virtual Health Systems
US Person-Centered Virtual Health
System National Standards Info Exchange /
Sharing High Performance Info Systems Personal
Health Systems/ Records
Health Information Systems (EHR, PHS/R, Exchange)
Standards
2001
2010
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Charge for VAs EHR to Meet Needs Beyond VA

• Within 90 days, the Secretary of Veterans
  Affairs and the Secretary of Defense shall
  jointly report on the approaches the Departments
  could take to work more actively with the private
  sector to make their health information systems
  available as an affordable option for providers
  in rural and medically underserved communities.
• President Bushs Executive Order 13335 April
  27, 2004

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VistA Is Being Enhanced For Use By Non-VA
Providers

• VA is partnering with Centers for Medicare and
  Medicaid Services (CMS) to ensure availability of
  high quality, standardized, interoperable and
  affordable electronic
• Hope to stimulate broader adoption effective
  use of EHRs
• VistA - Office EHR
• A version of VistA configured to be affordable
  and to meet the needs for use in community health
  clinics and office based practices in rural and
  underserved areas
• Goal to make an EHR available to 1-8 physician
  practice
• Doctors Office Quality Information Technology
  (DOQ-IT) connectivity to VistA Office EHR
• Enhancements will be incorporated into core VistA
  will reflect changes made in core VistA only
  1 version of VistA
• Expected release August 2005
• More information at http//www.cms.hhs.go
  v/quality/pfqi.asp

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Current VistA Is Already Used Elsewhere

• Currently used by several non-VA organizations
  (partial list)
• Indian Health Service (modified version of VistA)
• Egyptian National Cancer Institute
• American Samoa
• DC Department of Health
• Oklahoma State Dept. of Veterans Affairs (State
  Veterans Homes)
• Other healthcare organizations are exploring the
  use of VistA