Eglin Site Visit Steve Steffensen, MD Eglin AFB Site Visit February 14, 2007 AHLTA Update Naval...

Eglin Site VisitSteve Steffensen, MD

Eglin AFB Site VisitFebruary 14, 2007

AHLTA UpdateNaval Hospital Pensacola

Steve Steffensen, MDLT, MC, USN

Head, NHP [email protected]


Review the following:

• AHLTA Introduction at NHP (The who, what, when…)

• Preparation Creation of the AHLTA “Task Force”

• “Hot Topics” and “Top 5” at NHP

• The NHP Approach to EMR acceptance(a work in progress…)

Objectives

Eglin Site VisitSteve Steffensen, MDAHLTA Background Information

• Rough Timeline of DoD EMR Activity Related to NHP:– 01/2004:

• 01/20/2004: President Bush “State of the Union” address (Improving care via EMR)

• Initial implementation phase of CHCS-2 begins.– 04/26/2004:

• Presidential Executive Summary: Most Americans will have EHR in the next 10-years

– 11/21/2005:• Name of CHCS2 formally changed to AHLTA.

– 03/06/2006:• AHLTA 838 training begins at Pensacola (Millington Brach Clinic).

– 06/29/2006:• AHLTA 838 training complete in main hospital.

Eglin Site VisitSteve Steffensen, MDAHLTA Preparation

• What is the civilian sector doing for Electronic Medical Records?

– >74 commercially available EMR systems.

– >75% of clinicians either have an EMR or are planning on purchasing soon.

– 20% of clinicians are using Voice Recognition Software

– 46% of clinicians are using coding software

• What about Primary Care and the ability to deliver standard of care in the current environment (without AHLTA)?

– NEJM, 08/31/2006: “Primary Care – Will It Survive?”

• “It has been estimated that it would take 10.6 hours per working day to deliver all recommended care for patients with chronic conditions, plus 7.4 hours per day to provide evidence-based preventative care.” (based on average patient panel of 2500)

Eglin Site VisitSteve Steffensen, MDAHLTA Preparation

• What was the status of AHLTA at DoD?

– Greater than 1.8 million outpatient encounters per week.(approaching 100,000 per day with CDR expansion terabyte/month)

– Approximately 1 million structured MedCin terms per day.

• How does AHLTA interact with local hardware at NHP?

– 838.19 installed on over 1300 machines at Navy Hospital Pensacola

– 838 LCS: Nightly routines take approximately 4.5 hours to complete.

• >34 nightly processes

• >22 scheduled tasks

– Who owns the LCS (Local Cache Server)?

– Who owns the local database on the LCS?


• What are MedCin terms? Where did they come from?

– Initially conceived by Peter Goltra in 1978 for Medicomp

– Expanded considerably since that time:

• Over 250,000 total terms today

– Favorites: “membership in Bantu tribe”, “dependence on an iron lung”, “A recent epidemic of sick or dead monkeys.”, etc…

• Over 85,000 individually reviewed physical findings

• Over 43,000 diagnoses individually reviewed for complexity/risk assessment

– MedCin terms currently used by:

• WebMD?

• Epic (Kaiser Permanente reportedly spending $3 billion on IT)

• DoD AHLTA

– Competitors (“codified databases”)

• SNOMED (developed by College of American Pathologist)

• LOINC (developed by Regenstrief Institute for Healthcare)

AHLTA Preparation


Who’s in charge?

(where is the organizational chart?)


SAIC(Science Applications International Corp.)Developed CHCS in 1988 for $1 billion.

Founded 02/03/1969. Contract via CITPO

CDR(Clinical Data Repository)

Oracle database housed on HP Unix servers in Montgomery, AL

Growing >1 terabyte/month

TIMPO(Tri-Service Infrastructure Management Office)

Lan/Infrastructure of AHLTA

Northrop Grumman(acquired Integic 03/18/2005)

CITPO(Clinical Information Technology Program Office)

Under ASDHA. DoD managers of AHLTA.

IntegicBased in Chantilly, VA.

Maintains AHLTA program“the programmers” and Tier 3 trouble tickets

Contract via CITPO

AHLTA / CHCS-2(Armed Forces Health

Longitudinal Technology Application)Started 01/2004. Name change to AHLTA 11/21/2005.

$5 billion project – expected life-cycle FY 2021Estimated Sustainment Cost: $6 million/year

ASDHA(Assistant Secretary of Defense for Health Affairs)

Honorable William Winkenwerder

TMA / MHS(Tri-care Management Activity Office)(Military Health System – Tri-Service)

Legacy CHCS(Composite Health Care System)

$1 billion project – 8-year initial contract

Secretary of Defense

BUMED(Bureau of Medicine and Surgery)

SECNAV(Secretary of the Navy)

CNO(Chief of Naval Operations)

NMSC(Navy Medicine Support Command)

NMIMC(Navy Medicine Info Management Center)

XO: CDR Ortiz

Staff Corp(Medical, Dental, Nurse, Medical Service, etc)

Dr. Bowes, Dr. Steffensen

DISA(Defense Information Systems Agency)

Established 05/12/1960Contract via CITPO

Draft AHLTA organizational chartPrepared by: LT Steve SteffensenNavy Hospital PensacolaUpdated: 01/22/2007

M3 Clinical Operations(Clinical Champions for AHLTA)

Set policy and discuss global issues with AHLTADr. Shapiro

AHLTA Program Office(Program Manager: Rolando Estrada)

AHLTA Deployment Office

IBMAHLTA Trouble Tickets (Tier 1 and 2)

Contract via CITPO

Lockheed Martin

End User Relations

E2E Solutions

Eglin Site VisitSteve Steffensen, MDLessons Learned in Preparation

• “Is AHLTA the Medical Record?”vs. “AHLTA is the Medical Record”

• AHLTA is unlikely to disappear.• Get organized, look for future trends, and

network/communicate with other commands within DoD.

• Identify problems and label accordingly:– Strategic MHS issues.– Operational Local MID/IT issues.– Tactical Local provider-level issues.


• Distinct 2 Phase AHLTA Template Implementation:– Phase 1: (complete)

• Identify “Template Champions” at Command.• Create “Encounter Templates” based on patient population.• Build acceptable S/O sections and solid A/P sections.

– Phase 2: (currently underway)• Develop “Hot Topic” and “Top 5” List.• Revise existing S/O section (AIM form revision)

– Use dictation as gold standard.– AIM forms that reflect current clinical practice at NHP.

• Periodic review of CPG’s, Coding Essentials, and Data Quality.• Become DoD test site for “Future Trends”.

NHP AHLTA Implementation


AHLTA Task Force

Test Pilot Group

NHP AHLTA Policy GroupPhysician weighted

Work arounds

New “build” testers

MID IT Support(Security Compliance, Software Oversight, Hardware Oversight)

Role masters

Standard Look/Feel

CPG and Coding

Think outside the form

AIM Form Group

Standard Look/Feel

Database backend

AIM form support

Web Group

(VRS, patient kiosks, corpsman AIM forms, tablet PCs, etc)

Sustainment

CD/Handouts

Scheduling

Training Group

Updated: 09/20/2006

Data Quality Manager

JCAHO/PI Policy

Coding Policy

NHP AHLTA Task Force Organizational Chart

Patient AdminMedical Records

TATRC

Dragon VRS

Tablet PC

Research & Development

Group

Wireless

NMIAT

JAG/Legal?Healthcare Ops?ECMS/ESC

On to Phase 1


Medcin List

Medcin Template

AIM Form Template

S/O Template Evolution

The word “template” means different things at different commands…


AIM Form Template(with CPG criteria when

available)

A/P Template(top ICD9, CPT, Order Sets,

and Other Therapies)

Encounter Template(Managed and reviewed by Template Champions)

“Encounter Template” Defined

Acceptable S/O templatesbased on currently available

AIM forms…Solid A/P templates

created by“Template Champions” at command

Currently over 114MTF Encounter Templates

Eglin Site VisitSteve Steffensen, MDPoor S/O Quality

On to Phase 2


• Who has quality control over patient care documentation?AHLTA is a MEDICAL RECORD… What are our responsibilities?

• Medication Reconciliation and JCAHO NPSG Compliance

• Problem Summary List vs. Past Medical/Surgical History

• Special Communities in Military Medicine (Flight, Dive, Deployed, etc)

• Accurate Auditable Coding and RVU capture– Pay for Performance…need I say more?

– Resident/Intern coding accuracy (how do they know how to code?)

– Resident/Intern GME? How do you teach the skill of documenting patient care?

– 1995 versus 1997 Medicare coding guidelines (Army vs. Navy vs. Air Force vs. AHLTA)

“Hot Topic” Areas of S/O Module


• “Top 5” Defined: AHLTA trouble tickets at the MTF level that either directly impact patient safety or a providers ability to deliver standard of care.

– “Fix one, Add one” philosophy.

– Routinely forwarded up the chain to CITPO/MHS.

– Gives CITPO visibility to the most critical issues from MTF perspective.

– Has evolved to include both clinical and MID/IT “Top 5” issues.

• Update on “Top 5” Status:

– Since starting this in 04/2006, two items have been fixed.

– Requires local and MHS level tracking of trouble tickets.

– Most recent addition: 09/27/2006 (MHS #12655121) Incorrect diagnosis displays in preview pane of previous encounters.

• Next likely candidate:

– Incomplete encounters mismatch between CHCS1 and AHLTA Affecting RVU calculations for command (SADR).

“Top 5” Trouble Tickets

Eglin Site VisitSteve Steffensen, MDUpdating the AIM Forms

• First: Review current expectations of AIM form MedCin terms.

MedCin Terms in AIM forms should be used to:

• Write the content of the S/O note.

• Capture coding information (for “automatic” coding)

• Capture useful data for data mining (CPG, etc)

• Second: Determine how many MedCin terms are actually needed if you do not use the MedCin terms to write the S/O note.

– Each AIM form tab can hold ~100 terms…but only ~34 are needed for a level 5 encounter. After 34…diminishing returns.

• Third: Determine which MedCin terms are useful to ideally capture both coding information and data for CPG/Epidemiology.

• Forth: Work with existing template champions and “Policy Group” to develop a prototype that can be used for various conditions.

Eglin Site VisitSteve Steffensen, MDStep 1: Decipher AHLTA Coding

Eglin Site VisitSteve Steffensen, MDStep 2: Decipher AIM Forms

AIM fo

rm code

Eglin Site VisitSteve Steffensen, MDStep 3: Develop a Prototype

• Features of ideal AIM form (within confines of AHLTA):– Driven by “free text” to create a note similar to dictation.

– Utilize resources (coders, JCAHO rep, DQ, template champions) to capture clinically/MTF relevant MedCin terms.

– Allow easier access and integration with online and commercial products from within the note including MTF intranet resources.

– Utilize clinic staff to maximize efficiency.• Corpsman/Medic/Nurse AIM forms…

– Allow direct dictation into the note where possible.

– Standardization across the platform.

Eglin Site VisitSteve Steffensen, MDDiabetic AIM Form Prototype

Eglin Site VisitSteve Steffensen, MDGeneric AIM Form Prototype


1


2


3


4


MORE ACCURATE THAN EVER BEFORE!With up to 99% accuracy and the capability to understand up to 160 words per minute, Dragon Naturally Speaking 9 is typically more accurate than typing. Build custom vocabularies for your topics and attain even higher accuracy.

Dragon Naturally SpeakingVoice Recognition Software

Medical Version 9

Eglin Site VisitSteve Steffensen, MDHeadache AIM Form Prototype


FMP/SSN 20/123-45-6789

xx/xxx-xx-xxxx

Navy Hospital PensacolaPatient Medication List Resource

THIS IS A DEPARTMENT OF DEFENSE COMPUTER SYSTEM

This computer system, which includes all related equipment, networks, and network devices (specifically including access to the internet), are provided only for official U.S. Government business. Department of Defense computer systems may be monitored by authorized personnel to ensure that their use is authorized, for management of the system, to facilitate protection against unauthorized access, and to verify security procedures. Monitoring includes 'hacker' attacks to test or verify the security of this system against use by unauthorized persons. During these activities, Information stored on this system may be examined, copied and used for authorized purposes and data or programs may be placed into this system. Therefore, information you place on this system is not private. Use of this Department of Defense computer system, authorized or unauthorized, constitutes consent to official monitoring of this system. Unauthorized use of a Department of Defense computer system may subject you to criminal prosecution. Evidence of unauthorized use collected during monitoring may be provided to appropriate personnel for administrative, criminal or other action.

Information contained in this system is subject to the Privacy Act of 1974 (5 U.S.C. 552A, as amended). Personal information contained in this system may be used only by authorized persons in the conduct of official business. Any individual responsible for unauthorized disclosure or misuse of personal information may be subject to a fine of up to $5,000.


Automatically converts “QD” to daily, “QHS” to at bedtime, etc.

Eglin Site VisitSteve Steffensen, MD“Proof of Concept”


This area holds about 2000 characters.


Identify those MedCin terms that asan MTF or department you wish toknow about your patients with Diabetes.

Eglin Site VisitSteve Steffensen, MDBack Pain AIM Form CPG Tab

Eglin Site VisitSteve Steffensen, MDNHP Diabetes CPG Intranet Page

Can be any internetor intranet webpage.

Best of all, you canlink to other resourcesand print the page.

Eglin Site VisitSteve Steffensen, MDListing of Template Champions


Diabetic AIM Form Prototype


Final Outcome?

Eglin Site VisitSteve Steffensen, MDWish List


Grace Bella Steffensen

Eglin Site VisitSteve Steffensen, MDResources

• President Bush’s Executive Summary (04/26/2004)

– http://www.whitehouse.gov/infocus/technology/economic_policy200404/innovation.pdf

• VA Initiatives for integration with AHLTA

– http://www1.va.gov/vadodhealthitsharing/

• Committee on Appropriations (HR 5385)

– http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=109_cong_reports&docid=f:sr286.109.pdf

• “Solving the Tech Puzzle”, Physicians Practice: September 2006

• “Primary Care – Will It Survive?”, NEJM: August 31, 2006

Eglin Site Visit Steve Steffensen, MD Eglin AFB Site Visit February 14, 2007 AHLTA Update Naval...

Documents

Transcript of Eglin Site Visit Steve Steffensen, MD Eglin AFB Site Visit February 14, 2007 AHLTA Update Naval...