Health Tech Net July 15, 2005

Health Tech Net

July 15, 2005

Robert M. Kolodner, MDActing Deputy CIO for Health &

Acting Chief Health Informatics Officer

Veterans Health AdministrationDepartment of Veterans Affairs

Health Tech Net July 15, 2005 2

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 PhysiciansAlmost 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


VistA’s 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 (n=158)

$3.6 million

• Delivers a complete hospital information system, electronic health record, imaging, BCMA

– Hardware, software, maintenance, upgrades, staffing


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 workdayStatistics as of June 2005


“ . . . 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/KnowledgeCenter/hipaa/elearning/QC_govt.htm

. . . Because healthcare (in the U.S.) is a trillion-dollar cottage industry! ”

Medical Computing Status


Except in VA !Except in VA !

Every VA Medical Center has Electronic Health Records !


Praise for VistA…

“VHA’s 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)”


(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 & CIO

Partners (Harvard) HealthCare System


However

This is NOT about technology…

It is about RESULTS:

•Improved Health Care Quality

•Improved Health Outcomes


And in January 2005…


Performance MeasurementSetting the U.S. Benchmark for 18 Comparable Indicators

Clinical Indicator VA 2003 Medicare 03 Best Not VA or Medicare

Advised Tobacco Cessation (VA x3, others x1) 75 62 68 (NCQA 2002)

Beta Blocker after MI 98 93 94 (NCQA 2002)

Breast Cancer Screening 84 75 75 (NCQA 2002)

Cervical Cancer Screening 90 62 81 (NCQA 2002)

Cholesterol Screening (all pts) 91 NA 73 (BRFSS 2001)

Cholesterol Screening (post MI) 94 78 79 (NCQA 2002)

LDL Cholesterol <130 post MI 78 62 61 (NCQA 2002)

Colorectal Cancer Screening 67 NA 49 (BRFSS 2002)

Diabetes Hgb A1c checked past year 94 85 83 (NCQA 2002)

Diabetes Hgb A1c > 9.5 (lower is better) 15 NA 34 (NCQA 2002)

Diabetes LDL Measured 95 88 85 (NCQA 2002)

Diabetes LDL < 130 77 63 55 (NCQA 2002)

Diabetes Eye Exam 75 68 52 (NCQA 2002)

Diabetes Kidney Function 70 57 52 (NCQA 2002)

Hypertension: BP < 140/90 68 57 58 (NCQA 2002)

Influenza Immunization 76 P 68 (BRFSS 2002)

Pneumocooccal Immunization 90 P 63 (BRFSS 2002)

Mental Health F/U 30 D post D/C 77 61 74 (NCQA 2002)


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


Current VistA

HealtheVet-VistA

HealthePeople-VistA

Agenda


Past and Present


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


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


In 1996, VA launched the “Computerized Patient Record System”

-- CPRS-- a comprehensive, integrated

Electronic Health Record (EHR)


VistA’s 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


Electronic Health Records &Computerized Provider Order Entry

•Computerized Provider Order Entry (CPOE) is one of the Leapfrog Group’s “Top 3 Safety Strategies”

Outside of VA, CPOE < 8% nationally< 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


Clinical Reminders

Contemporary Expression of Practice Guidelines

• Time & Context Sensitive

• Reduce Negative Variation

• Create Standard Data

• Acquire health data beyond care delivered in VA


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


Next Generation VistA……..

The Future


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


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)


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 “COOP’ed”

[Continuity of Operations]

•Modernization effort includes– Systems Platform– Software Design– Development Methodology


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


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 standardsStart 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


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.


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 VHAIncreases patient safety across VHAWill exchange pharmacy & allergy information with DoD for patients receiving health care in both systems

–Provides real-time interaction detection for both VA & DoD data


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


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


Personal Health Records


•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

My HealtheVet (Phase 1) Veterans Day 2003

www.myhealth.va.gov

Principles:


Three Iterative Implementation Phases:

Content Contributors

PHASE 1November 2003

Engagement

Showcasing

Health Populations

Health Tools

VA Services

Personalization

Prescription Refill

Self-Entered Information

View Appointments

View Co-Pay Balance

Self-Entered Metrics

Electronic Health Record

PHASE 2November 2004 –

Summer 2005

PHASE 3Fall/Winter 2005-2006

Clinician / Patient Messaging

Parallel Tracks

Moderated Discussion

On-Line Education / Training

My HealtheVet

My HealtheVet is a new ehealth portal where veterans, family, and clinicians may come together to optimize veterans’ health care. What’s Coming……


“To be” (VA & Beyond)

Progress Toward US “Virtual Health Systems”

2001 2010

US Person-Centered “Virtual

Health System”

National Standards

Info Exchange/ Sharing

High Performance Info Systems

Personal Health

Systems/ Records

Convergence

VA, DoD, IHS individual/joint adoption

National -- Public/Private•Individual (e.g. Kaiser Permanente)•Joint (NHII, Connect. Health, eHI, HIMSS, NCVHS, SDOs, etc.)

HealthePeople(Fed)

HealthePeople

Consolidated Health Informatics (CHI)

Conve

rgen

ce

DoD CHCS II & TRICARE Online

IHS (upgraded RPMS)

National – Public/Private•Individual (health providers/payers/regulators, private sector vendors)•Joint (NHII, CMS/VA, Connect. Health, etc.)

HealthePeople(Fed)

HealthePeople

VA HealtheVet/People-VistA & My HealtheVet

Hea

lth

In

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Sys

tem

s (E

HR

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S/R

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Charge for VA’s 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 Bush’s Executive Order 13335 – April 27, 2004


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.gov/quality/pfqi.asp


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

Health Tech Net July 15, 2005

Documents

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