Management using Health Information System George Mason University December 1, 2006 Syed Tirmizi, MD Medical Informatician Veterans Health Administration

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Management using Health Information System
George Mason UniversityDecember 1, 2006Syed
Tirmizi, MDMedical InformaticianVeterans
Health Administration
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Veterans Health Administration

• 5.3 million patients, 7.7 million enrollees
• 30 Billion budget
• 1,400 Sites-of-Care
• 198,500 Employees (14,500 MD , 58,000 Nurses,
  33,000 AHP)
• Affiliations with 107 Academic Health Systems
• 1.7B Research Rehabilitation, Health Services,
  Clinical, Basic

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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
• 70 with annual incomes lt 26,000
• 40 with annual incomes lt 16,000
• Changing Demographics
• 7.0 female overall
• Females 22.5 of outpatients less than 50 years
  of age

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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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VAs Health Information System .VistA

• CPRS is the integrated EHR application
• VA runs 128 VistA systems
• Down from 172 VistA systems 10 years ago
• Delivers a complete hospital information system,
  electronic health record, imaging, Bar Code
  Medication Administration
• Hardware, software, maintenance, upgrades,
  staffing
• For FY2004
• Cost per enrollee
• 78 / enrollee
• Average cost per hospital (n158)
• 3.6 million

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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 15 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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Uses a Chart Metaphor - Combining Text and
Images

• Single longitudinal health record is immediately
  available in
• Outpatient
• Inpatient
• Long-term care settings

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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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Informatics Support for Clinical Practice
Guideline Implementation
Pathman, et al. Medical Care 1996 34873-889
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Bar-Code Medication Administration (BCMA)
BCMA Assures Right Medication Right Dose
Right Patient Right Provider Right Time
Virtually Eliminates Errors at the Point of
Administration . . . Coming Soon Bar-Coded
Lab Specimen, Blood Administration, more
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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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How Do We Compare to non-VA Providers? VHA
Continues to exceed HEDIS in the vast majority of
17 common measures
HEDIS Health Plan Employer Data Information
Set From the National Committee on Quality
Assurance (NCQA)
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How Do We Compare to non-VA Providers? VHA
Continues to exceed HEDIS in the vast majority of
17 common measures
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FY99-04 Changes in Total, Major and Minor
Age-Adjusted Amputation Rates Among Patients With
Diabetes
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Vaccine Cuts Pneumonia Risk in High-Risk Patients

• 50 of elderly Americans / high-risk individuals
  have not received the pneumococcal vaccine.
• VA Medical Center study of 1,900 elderly patients
  with chronic lung disease 2/3 vaccinated against
  pneumonia.
• Pneumococcal vaccination
• 43 reduction in hospitalizations for pneumonia
  and influenza, and a 29 reduction in the risk of
  death.
• Pneumonia and Influenza vaccination
• 72 reduction in hospitalizations for these two
  diseases and an 82 reduction in deaths from all
  causes.
• Pneumococcal vaccination saved an average of 294
  per vaccine recipient over the 2-year period.
• Archives of Internal Medicine 19991592437-2442
  Dr. Kristin Nichol, VAMC / Minneapolis

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Pneumococcal Vaccination Rates in VHA
--BRFSS 90th--
--BRFSS--

• Iowa Petersen, Med Care 199937502-9. gt65/ch dz
• HHS National Health Interview Survey, gt64

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Ten Year Cumulative Percent Change in Costs -
VA, Medicare, CPI

• VHA Cost per Patient Total Medical Care
  Obligations per Total Unique Patients (including
  non Veterans)
• Average Medicare Payment per EnrolleeMedicare
  Program Benefits per Enrollee (www.cms.hhs.gov/res
  earchers/pubs/datacompendium)
• Medical Consumer Price Index-- Bureau of Labor
  Statistics (household out of pocket medical
  expenses including insurance and co-payments)

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Home Telehealth Technologies
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PHRPersonal Health Record
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Research Harris Interactive

• Two in five adults in the US keep their own
  personal and family health records.
• 13 keep them electronically
• 40 planning to do so in the future
• More women (45) than men (38) kept records.
• 58 of the over-65s filed information about their
  treatment.
• 84 of all surveyed welcomed the Personal Health
  Record (PHR) concept.
• Out of the 13 in the Harris survey who kept
  electronic records, only one in thirteen kept
  them online at a health record website.
• Source Harris Interactive, August 2004

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What Do Patients Value in a PHR?
Angst, C. M., Agarwal, R. (2004) Patients Take
Control Individual Empowerment with Personal
Health Records, Center for Health Information
and Decision Systems.
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Predictors of PHR Use or Desire for Use

• Convenience is a strong predictor of desire for
  PHR1
• Compliance is a predictor of PHR use2
• Connectedness is a predictor of PHR use2
• Age and Chronic Illness were not predictors but
  Education and Knowledge of PHRs were predictors
  of desire for PHR3
• 1Angst, C. M., Agarwal, R. (Working Paper).
  Getting Personal About Electronic Health
  Records Modeling the beliefs of personal health
  record users and non-users,
• 2Agarwal, R., Angst, C. M. (2006).
  Technology-Enabled Transformations in U.S.
  Health Care Early Findings on Personal Health
  Records and Individual Use, In D. Galletta P.
  Zhang (Eds.), Human-Computer Interaction and
  Management Information Systems Applications
  (Vol. 5). Armonk, NY M.E. Sharpe, Inc.
• 3Angst, C.M., Agarwal, R., Downing, J. (Working
  Paper). An Empirical Examination of the
  Importance of Defining the PHR for Research and
  for Practice, Under Review.

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How comfortable would you be if an PHR was
provided, sponsored, and/or maintained by
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The Chronic Disease Care Model
Health System
Community
Resources and Policies
Organization of Health Care
Self-Management Support
VistA
DeliverySystem Design
Decision Support
Productive Interactions
Informed, Empowered Patient and Family
Prepared, Proactive Practice Team
My HealtheVet
Improved Outcomes
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What do people with Chronic Disease need?

• A continuous healing relationship.
• Regular assessments of how they are doing.
• Effective clinical management.
• Information and on-going support for
  self-management.
• Shared care plan.
• Active, sustained follow-up.

Ed Wagner presentation Beyond the Basics
Another Look at the Care Model
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Benefits to Providers

• Transfer the ownership of chronic disease
  management to the patient.
• Offers more complete picture of patients health
  conditions and health care, including non-VA
  care.
• Reallocation of time in practice to more complex
  cases.
• Ability to communicate and collaborate with
  patients more easily.
• A study by McKay et al found that patients who
  participated in an online diabetes education and
  support group lowered their blood glucose levels
  significantly more than controls did.

• McKay HG, King D, Eakin EG, Seeley JR, Glasgow
  RE. The diabetes network Internet-based physical
  activity intervention
• randomized pilot study. Diabetes Care 2001
  Aug24(8)1328-1334.

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Benefits to VHA

• One single touch point to reach entire veteran
  population.
• Broadcast health bulletins (e.g., SARS, flu
  shot).
• Interactive outreach to veterans for health
  education, VA specific programs, opportunities to
  participate in research programs, etc.
• Enhanced patient satisfaction.

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Its all about the veteran

• What does person-centric care look like?
• Care where the patient is the focus of control.
• Care that integrates across environments.
• Care that integrates across health disease.
• Care that anticipates needs rather than just
  reacts to it.
• Care that works with the patient in
  non-traditional environments.

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2006 Innovations in American Government Award
Winner
Visit www.innovations.va.gov
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VA s Use of Health IT Technology

• VA has adopted a culture of patient safety
  and quality that is pervasive," says Karen Davis,
  president of Commonwealth Fund, which studies
  health-care issues. The centerpiece of that
  culture is VistA, the VA's much praised
  electronic medical-records system.
• VistA has also turned out be a powerful force
  for quality control.
• Business Week
• July 17, 2006

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Articles About VAs Info Technology Quality
In summary, electronic health records,
performance management, and a patient-centric
focus have been critical transformational
strategies for the VA. They have been utilized to
support achievement and are associated with
measurable progress in each of the VAs value
domains. The American Journal of Managed Care,
November 2004

• 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)

Annals of Internal Medicine, December 21, 2004
Annals of Internal Medicine, August 17, 2004
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VA s Use of Health IT Technology

• Veterans hospitals used to be a byword for
  second-rate care or worse. Now theyre national
  leaders in efficiency and quality. What cured
  them? A large dose of technology.
• Fortune
• May 15, 2006

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Recent Praise for VistA

• Despite my private sector credentials and
  experience, it is my duty to tell you that the
  current, comprehensive electronic health
  environment of the Veterans Health Administration
  surpasses any capability available today on the
  planet, whether in the private sector, other
  departments of the U.S. government, or the highly
  profiled activities of other countries.
• Jonathan C. Javitt, M.D., M.P.H. (former
  Co-Chair, Health Care Delivery and IT
  Subcommittee, Presidents Information Technology
  Advisory Committee)
• Testimony before the House Committee on
  Veterans Affairs, Subcommittee on Oversight and
  Investigations September 28, 2005

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VistAs Contribution to the High Quality Care
Provided By VA

• 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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Highest Quality of Care For Patients with
Diabetes in VA

• Diabetes processes of care and 2 of 3
  intermediate outcomes were better for patients in
  the VA system than for patients in commercial
  managed care.
• Annals of Internal Medicine, August 17, 2004

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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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(Still More) Praise . . .

• 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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Success In Supporting Health Care Delivery For
Millions Of Veterans

• VistA is a success
• Built by fire of VHA collaboration
• Publicly owned by VA
• Strong interest by public/private in using VistA
• National software w/ local flexibility/innovation
  
• Innovation developed locally enterprise wide
• Standard packages distributed enterprise wide,
  e.g. latest version of CPRS
• Initial system (1983-1996) was built around dumb
  terminals
• Decentralized Hospital Computer Program (DHCP)
• Steady deployment of packages and enhancements
• Applications separated out by Hospital/Clinic
  Service
• Simple roll-and-scroll screens

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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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Information Exchange
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DoD/VA InteroperabilitySolution Suite
DoD
VA
One-way, enterprise exchange of text data
FHIE
FHIE
Bidirectional, real-time exchange of text data
BHIE
BHIE
Bidirectional, real-time, enterprise exchange
of computable data
CHDR
CHDR
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American Health Information Community (AHIC)

• On September 13, 2005, Department of Health and
  Human Services announced the creation of American
  Health Information Community (AHIC).
• formed to help advance efforts to reach
  President Bushs call for most Americans to have
  electronic health records within ten years.
• federally-chartered commission and will provide
  input and recommendations to HHS on how to make
  health records digital and interoperable, and
  assure that the privacy and security of those
  records are protected, in a smooth, market-led
  way.
• More Info http//www.hhs.gov/healthit/ahic.html

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Health Information Technology Deployment
Coordination
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Sharing VAs Expertise

• Consolidated Health Informatics (CHI)
• Federal interagency initiative VA a founding
  partner
• Endorsed 20 data communication standards to
  date
• VistA-Office EHR (VOE)
• Collaboration with Dept. of Health Human
  Services to foster wider adoption of EHRs
• Based on VistA/CPRS, configured for physician
  office/clinic settings
• Beta version released by HHS for evaluation
• American Health Information Community (AHIC)
• Public-private collaboration to develop standards
  and increase interoperability of health
  information
• Certification Commission for Healthcare
  Information Technology (CCHIT)

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Definition

• Data Standardization refers to the
  identification, adoption, implementation,
  maintenance and compliance monitoring of data
  standards
• Data Standardization is foundational to sharing
  computable, interoperable data across a health
  care information infrastructure

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The Goals of Standardization

• Ensure consistent interpretation of clinical
  information
• Support clinical decision-making
• Support interoperability with health care
  partners
• Support public health and bio-surveillance
  activities
• Improve quality, safety, and cost-effectiveness
  of patient care

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VA Business Drivers for Data Standardization

• To support data exchange, comparison, aggregation
  and reporting among VHA sites
• To readily support clinical research efforts
• To support development of an integrated,
  longitudinal patient record
• To enable exchange of clinically relevant health
  data between VA, other agencies, and other health
  partners
• To enable decision support on patients complete
  medical record
• To reduce costs by eliminating redundant expenses

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External Business Drivers for Data Standardization

• Consolidated Health Informatics (CHI)
• Federal interagency initiative to develop
  standards for interoperability of health care
  information
• Part of Presidents eGov initiative
• 20 federal participants, including VA, DoD, HHS,
  NIH, IHS, CDC, FDA
• Clinical Data Repository/Health Data Repository
  (CHDR)
• Congressionally mandated
• Support interoperability between VA and DoD
  systems
• Decision support based on information from both
  agencies
• Deliverables for 4 domains Vitals, Outpatient
  Pharmacy, Allergies, and Lab

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Laboratory Mapping

• Logical Observation Identifiers Names and Codes
  (LOINC)
• Created by Regenstrief Institute
• Provides standard, universal list of names and
  codes
• Allows comparison of results across systems
• VA lab test usage
• Lab tests created locally with varying names
• 197,000 lab tests now mapped to LOINC

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Decentralized Note Titles

• Progress notes visible from all VAs/DoD
• 156,000 active and in-use note titles
• Titles created locally/difficult to decipher
• AUDIO/REEVAL/HA CHECK (T)(CI)CH-SARP
  NOTECIH/STAR II CONSULTDME CLINIC
  (T)IC/ID/VMH-CWT PATIENT CHECKLIST (CH)
  NURSING PRRTP NOTE SOCIAL WORK BOMH
  DISPOSITION NOTE (O) (T) UR 67CD (T)(K)
• There are more than 1500 different titles for
  Infectious Disease Encounters alone
• Standardization will allow clinicians to quickly
  find relevant content

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Note Titles Standardized to LOINC Axes

• The LOINC document naming nomenclature contains
  five axes
• Subject Matter Domain Characterizes the subject
  matter of a note
• Role - Characterizes the training or professional
  level of the author of the document, but not
  specialty or subspecialty
• Setting Characterizes the general setting of
  the health care being provided. Setting is not
  equivalent to location
• Service - Characterizes the kind of service or
  activity that was provided to/for the patient
• E.g. examinations, evaluations, and management.
• Document Type - Characterizes the general
  structure of the document at a macro level.

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Implementation -- Mapping
Localnotetitle

• HEART FAILURE CLINIC FIRST VISIT NOTE

SUBJECT MATTER DOMAIN
SETTING
SERVICE
Cardiology
DOCUMENT TYPE
Outpatient
Initial evaluation
Standardizednote title
Note
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The Information Challenge

• Our ability to produce VA data has skyrocketed
  over the last 10 years
• proliferation of tools and technology for data
  collection and reporting
• proliferation of measures and monitors for
  managing and improving organizational performance
• The real challenge is not how to get data, but
  what data to focus on and how to best use data
  that is available.

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Information Dissemination

• Data used by VHA top management tends to be
  aggregated, summary statistics
• Enables quick, high level view of performance
• An increasing number of Composite measures are
  being developed and pushed down to the field
• A single score layered on top of multiple
  indicators

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ACRP

• Ambulatory Care Reporting Project
• enhances the process of collecting and storing
  encounter-based clinical, diagnostic, and
  administrative outpatient data
• information is a valuable database for resource
  utilization studies, forecasting, and healthcare
  planning for the future.
• ACRP Reports menu can return multiple reports
  when multiple divisions are selected. For
  example, if you select division A and division B,
  the output will contain a report for division A,
  a report for division B, and a report that
  reflects the combination of divisions A and B.

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ACRP

• DATA VALIDATION MENU
• ENC. BY DSS ID/DSS ID BY FREQ. (OP0, OP1, OP2)
• This option produces a report that returns
  statistics by DSS Identifier in a format
  that matches the Austin reports.
• MOST FREQUENT 50 CPT CODES (OP6)
• This option produces a listing of the 50 most
  frequent ambulatory procedure
• codes with associated provider type frequency
  in a format that matches the
• Austin report.
• MOST FREQUENT 50 ICD-9-CM CODES (OP7)
• This option produces a listing of the 50 most
  frequent diagnoses with
• associated provider type frequency in a
  format that matches the Austin
• ENCOUNTER ACTIVITY REPORT
• This option produces a report of encounter,
  visit, and unique patient
• statistics by selected clinic, provider, or
  stop code.
• ENCOUNTER ACTION REQUIRED REPORT
• This option is used to print a report of
  action required encounters in detailed or
  statistics format for a specified date range.

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ACRP

• Performance Monitor Menu
• The Performance Monitor Menu options are used for
  reporting Performance Indicator information.
  Information gathered is used to measure the
  percent of patient encounters in ambulatory care
  with a completed or amended electronic progress
  note signed by the primary provider for that
  encounter.
• Performance Monitor Summary Report
• This option is used to generate a report
  monitoring outpatient encounters, their
  associated progress notes, and the number of days
  it took providers to sign the notes.
• Performance Monitor Detailed Report
• This option is used to generate a detailed report
  on information pertaining to outpatient
  encounters and the progress notes associated with
  them.

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Clinical Reminders Performance Measures

• Clinical Reminders
• Real time decision support
• Targeted to specific patient cohort
• Targeted to specific clinic/clinicians
• Reminder Dialogs
• Standard documentation
• Capture of data (HF, IMM, encounter data, etc)
• Reminder Reports
• Performance improvement/scheduled feedback
• Identification of best practices
• Targeting low scorers for educational
  intervention
• Patient recall if missed intervention

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Clinical Reminder Reports

• A menu of Reminder Reports that clinicians can
  use for summary or detailed level information
  about patients due and satisfied reminders

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Clinical Reminder Reports

• Multiple Uses for Reminder Reports
• Patient care
• Future Appointments
• Which patients need an intervention?
• Past Visits
• Which patients missed an intervention?
• Action Lists
• Inpatients
• Which patients need an intervention prior to
  discharge?

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Clinical Reminder Reports

• Identify patients for case management
• Diabetic patients with poor control
• Identify patients with incomplete problem lists
• Patients with () Hep C test but no PL entry
• Identify high risk patients
• on warfarin, amiodarone
• Track annual PPD due (Employee Health)

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Clinical Reminder Reports

• Quality Improvement
• Provide feedback (team/provider)
• Identify ( share) best practices
• Identify under-performers (develop action plan)
• Track performance
• Implementation of new reminders or new processes
• Identify process issues early (mismatch of
  workload growth versus staffing)
• Provide data for external review (JCAHO)

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Clinical Reminder Reports

• Management Tool
• Aggregate reports
• Facility / Service
• Team (primary care team)
• Clinic / Ward
• Provider-specific reports
• Primary Care Provider
• Encounter location
• If one provider per clinic location

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Clinical Reminder Reports

• Employee Performance Evaluation
• Re-credentialing data for providers
• Annual Proficiency - Nursing
• Support for Special Advancement
• Support for Bonuses
• Employee Rewards Recognition

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The Vitals Report Example

• The Vitals Report is a summarization tool that
  has been layered on top of 61 performance
  indicators
• Its purpose is to create a single composite score
  that tells how a Network/Facility is performing
  relative those around it

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Vitals Report

• Uses Existing 5 Performance Domains
• Indicators scores are averaged within domains
• Equal weight for each indicator within a domain
• Assigns weights to each domain
• Access 30 (24 indicators)
• Functional Status 2.5 (2 indicators)
• Healthy Communities 2.5 (3 indicators)
• Quality 45 (30 indicators)
• Satisfaction 20 (2 indictors)
• Computes a weighted average across all domains
• Does not use performance targets

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Step 1 Figure Out What to Attack 1st

• If Composite Measure made from weighted averages
• Select highest weighted item with lowest
  performance
• If simple index (no weighting) or simple metric,
  select lowest performing indicator

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Getting One Measure for Trending
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Step 3 Graph the Data Over Time
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Using Cube to Analyze New Patient GI Wait Times
Problem is 32.84 at Green Facility
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Green Facility consistently poor performer over
time (15-33 )
Better in May
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Data Cube Trended Data
A single data point never tells you where you are
going or where you have been
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Computerized Patient Record System CPRS

• Improve healthcare outcomes
• Translate Clinical Practice Guidelines into
  clinical activities
• Real time decision support for clinicians at
  point of care reminders, alerts
• Prevent patient from falling through the cracks
• Avoid reliance on memory, vigilance
• Reduce errors (omissions, transcriptions, etc)
• Facilitate documentation for performance
  measurement and improvement efforts

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Links Reminder
With Actions
With Documentation
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Performance has improved
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Changed to include refusals as failures
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Outcomes have improved

• Increased rates of pneumococcal vaccination over
  past 5 years has averted over 4000 deaths
  nationally in VA patients with lung disease
• Diabetic complications markedly decreased
  amputations, peripheral neuropathy, visual
  impairment and loss

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Performance MeasurementA Key Driver
We could have the best operational system in the
world and still have lousy organizational
performance. There has to be an integrated,
cross organizational analytical system to monitor
performance, analyze performance, scrutinize
performance, and discover what and where the best
performance is.
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Top Business IntelligenceApplications for
Healthcare

• Disease specific data marts
• Performance measurement score card
• Monitoring provider performance
• Clinical Guideline hypothesis testing
• Compliance monitoring
• Research hypothesis testing
• Patient relationship management
• Cost effectiveness analysis
• Staff resource management
• Patient education

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Corporate Data Warehouse (CDW)

• What is the Corporate Data Warehouse?
• The CDW is a central collection of standardized
  databases integrating key enterprise wide
  clinical, administrative, and financial data to
  provide a unified view of VHA.
• CDW Strategy is a result of three primary
  factors
• Standard Information Business needs to have
  ready access to data to support management
  decision making.
• Standard Architectures Recognized value in
  standard platform, architecture, database
  structure and maintenance of CDW opposed to
  independent disparate Data Warehouse (DW) and
  Data Mart (DM) development by each business
  entity.
• Standard Tools The need to have modern, proven,
  robust access tools for reporting and analyzing
  data at the enterprise level.

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CDW Strategic Framework

• The CDW Will be Business Driven
• Information will be strategic and actionable
• Aligned with enterprise strategic objectives
• Common integration framework
• Feedback centric
• Maximize reuse, interoperability, and
  collaboration
• Leverage enterprise best practices

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Metadata CDW Portal
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Analytical Reporting Tools
Web Reporting
OLAP
Spatial Analysis

• Easy to learn and use
• Latest technology
• Variety
• Complimentary
• Standard access methods

SQL
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BI User Profiles

• Robust analysis tool
• Data mining
• Advanced visualization
• Predictive analytics

Analysts
5-10 of users

• Simple analysis tool
• Data visualization
• Simple filter/sort
• Easy publishing

Information Explorers
15-25 of users

• Robust reporting tool
• Access to reports
• Report subscriptions
• Browse/Search/View

Information Consumers (Incl. Executives)
65-80 of users
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VHA Report Portal

• Web based
• Parameterized reports
• OLAP cube access
• Dashboard access

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Clinical
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Diabetic Population Analysis
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(Patient Safety Research)
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99
Vitals by Type
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Operational
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Cost/Fill
Fills

• Compliance
• Contracts
• Clinical practice guidelines
• Performance measures

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Clinic Wait Times
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VHA Diabetic Patients by County (One or more
Inpatient or Outpatient ICD9 250.xx)
Pts by County
10,000 to 99,999
1,000 to 9,999
100 to 999
10 to 99
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1 to 9
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Administrative
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105
Provider Report Card
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106
Financial
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107
Workload Outpatient Pharmacy
108
Workload Outpatient Pharmacy
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Unique Pharmacy Patients by Qtr.
Blue Martinsburg VAMC Yellow Sister Site in
VISN
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Cost/Unique Patient by Quarter
Red Sister Site 1 within VISN Blue Sister
Site 2 within VISN Yellow Martinsburg VAMC
111
Top 20 Drug Cost by Month
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Search for Selected Documents
Select Text Integration Utilities (MIS Manager)
Option 4 Search for Selected Documents Select
Status COMPLETED// ? 1 Undictated 5
unsigned 9 purged 2 Untranscribed 6
uncosigned 10 deleted 3 Unreleased 7
completed 11 retracted 4 Unverified 8
amended Enter selection(s) by typing the
name(s), number(s), or abbreviation(s). Select
Status COMPLETED// 5,6 unsigned uncosigned
Select CLINICAL DOCUMENTS Type(s) Progress
Notes// ? 1 Progress Notes 3 Discharge
Summaries 5 Laboratory Reports 2 Addendum 4
Clinical Procedures 6 Surgical Reports
Enter selection(s) by typing the name(s),
number(s), or abbreviation(s). Select CLINICAL
DOCUMENTS Type(s) Progress Notes// 3 Discharge
Summaries Select SEARCH CATEGORIES AUTHOR// ? 1
All Categories 6 Patient 11
Transcriptionist 2 Author 7 Problem 12
Treating Specialty 3 Division 8 Service 13
Visit 4 Expected Cosigner 9 Subject 5
Hospital Location 10 Title Enter selection(s)
by typing the name(s), number(s), or
abbreviation(s). Select SEARCH CATEGORIES
AUTHOR// 8 Service Select SERVICE
SURGICAL Clinical Documents Jul 05,
2006_at_155752 Page 1 of 1
by SERVICE (SURGICAL) from 06/28/06 to
07/05/06 1 documents Patient
Document Ref Date
Status 1 TEST,TEST (T000) Discharge
Summary 07/03/06 uncosigned


113
Executive Dashboard
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114
Emergency Response
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115
New Orleans VAMC After Hurricane Katrina
Mon, Aug 29 Hurricane Katrina hits New
Orleans Tue, Aug 30 VAMC evacuation
begins Operational system shut down Stored
procedure based queries from DW made
available Wed, Aug 31 Web front end on DW queries
made available Thu, Sept 1 Secure, refined DW web
front end made available Mon, Sept 5 Permanent
front end (VistaWeb) made available
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116
Controllability Principle

• The idea of holding managers responsible for
  decisions in which they are given authority.
• Controllable Costs are costs affected by the
  managers decisions.

117
Data Validation

• Site Visits to review and analyze process and
  process variation in ordering and invoice
  verification etc.
• Identify Training Needs-Procurement Techs
• Data Validation Reports
• Monthly Unit Price Variance Reports-ProClarity
• High Cost Drug Report
• Cost/30 Day Rx Variance Reports-ProClarity
• Max Loss Savings Report- Mckesson

118
Decision-Making Criteria

• Cost Impact-
• What is the Cost Avoidance Potential?
• Safety of Change-
• What are risks, if any, to the patient?
• Resources-
• Level of Provider/Other stakeholders involvement?
• of staff hours it will take, versus what is
  available?
• Operational Impact
• How difficult is it to track?
• Time-
• How long it will take to accomplish (and how long
  until we can expect return on investment)?
• Other-
• Is it a National focus, or a VISN or Local
  priority, etc?
• Can we borrow something that has worked
  elsewhere?

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The Future is Now

• Increasing Data Volumes
• Increasing domains
• Clinical, Administrative, and Financial domains
• Telemedicine
• Genomics
• Clinical documents (unstructured data)
• Increasing Data Frequency
• Quarterly ? Monthly ? Semimonthly ? Weekly ?
  Daily ? Real time
• Increasing BI Capabilities
• Push technology (Mobile devices)
• Alerts
• Predictive analytics
• Point of care knowledge management (closed loop
  decision making)
• Text mining
• Search engines
• Increased capabilities of hardware (and lower
  cost)

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