# Presentation: 523745

## A World Class Electronic Health Record-Look What VA Has Done!#178

- Kevin Meldrum
- Gail Graham
- Marcia Insley
- Mike Hendry

## In January 2005...

*In January 2005...*

**Notes:**
Today’s troops are headed into the country’s best health care system  -- the VA healthcare system.

I have a copy of this article somewhere in my boxes – if you haven’t seen it or want to share it with staff.  It really is good and reflects highly on VA’s use of ITto achieve mission goals.

## Software Scope: Infrastructure

## Slide 4

## History

**Decentralized Hospital Computer Program (DHCP)** is the precursor of today’s system
- Decentralized approach allowed site level control
- Centralized applications were made available and were enriched by locally developed software
**VistA** has evolved to over 100 tightly integrated applications
- Built by hundreds of developers over thousands of man hours
- Inconsistencies in coded data

## Organizational Changes

## Delivers an integrated record covering all aspects of patient care and treatment
Includes electronic order entry and management, narrative notes entry, laboratory results display, consultation requests, alerts of abnormal results, and much more
“Remote Data View” and “VistAWeb” allow clinicians to see health data from any other VA facility where the veteran has received care

- Includes electronic order entry and management, narrative notes entry, laboratory results display, consultation requests, alerts of abnormal results, and much more
- “Remote Data View” and “VistAWeb” allow clinicians to see health data from any other VA facility where the veteran has received care

***VistA / *****CPRS**

***Computerized Patient Record System***

## Technology Stack

**Technology Stack**

## IT in the Clinical World

- An organism, when exposed to a new stimulus, will respond with one of these:
-  Adaptation
-  Rejection
-  Death

## Development Philosophy

## Collaborate Closely

- Synthesis of Professions
- Clinician, Medical Informatics, Developer
- Evolution of Mental Models
- Usability Testing
- Shadowing
- Role Playing
- Frequent Interactions

## Understand Adaptation

- Problem Space is NOT Solely Technical
- Issues are Coordination, Training, Workflow
- Software complexity is relatively low
- Predictability of Adaptation Decreases
- Requires small, incremental steps
- CPRS 1997-2000, 48 releases
- Locally Configurable and Extensible

## Share Nationally

- Well Chosen Standards
- Facilitate Sharing with Standards
- Local Innovation Becomes Reusable

*Standardization is the friend of customization.*

## Embrace Simplicity

- Deliver the essentials first
- Leverage simple technologies

- “I wouldn't give a fig for the simplicity on this side of complexity;
-  I would give my life for the simplicity on the far side of complexity.”
-                                                                     -Oliver Wendell Holmes

## Most Common Requirements

- It must be FAST.
- It must be easy to use, straightforward.
- It must be FAST.
- It must be accurate and reliable.
- It must be FAST..

## General Functionality

- etc.

## The First “GUI”

## Evolving Success

## Slide 19

## Where are we Now!!

- 	**Every VA Medical Center has ****Electronic Health Records !**

## Some National VistA Statistics(Total ... Daily)

**906,000,000**.......... **+640,000 each workday**
**Orders**
**1.7 Billion**............. **+960,000 each workday**
**Images**
**641,700,000**......... **+913,000 each workday**
**Medications Administered**with the Bar Code** **Medication Administration (BCMA) system
**885,000,000**......... **+620,000 each workday**

- Statistics as of Mar 2007

- Some National VistA Statistics(Total ... Daily)

**Notes:**
Stats as of June 2006

## Success in Supporting Health Delivery for Millions of Veterans

*VistA/CPRS supports the largest integrated healthcare system in the United States *
*serving over 5 million veterans*
- Single longitudinal health record is immediately available in inpatient, outpatient, and long-term care settings

## However......,

- This is **NOT** about building
- an IT system...
- It is about _**RESULTS:**_** **
***Improving Health Care Quality***
***Improving Health Outcomes***

**Notes:**
This is Perlin’s big nut – it speaks for itself.

## The Veterans Health Administration’s Future of Electronic Health Records

- Gail L. Graham, RHIA
- Director Health Data and Informatics
- Veterans Health Administration
- US Department of Veterans Affairs

## VHA EHR Recognized

**July 2006**

## Slide 26

## Quality Measures

| CLINICAL PERFORMANCE INDICATOR | VA FY 05 | HEDIS (2)   Commercial 2004 | HEDIS (2)           Medicare 2004 | HEDIS (2)              Medicaid 2004 |
| --- | --- | --- | --- | --- |
| Breast cancer screening | 86% | 73% | 74% | 54% |
| Cervical cancer screening  | 92% | 81% | Not Reported | 65% |
| Colorectal cancer screening | 76% | 49% | 53% | Not Reported |
| LDL Cholesterol < 100 after AMI, PTCA, CABG | Not Reported       (3) | 51% | 54% | 29% |
| LDL Cholesterol < 130 after AMI, PTCA, CABG | Not Reported       (3) | 68% | 70% | 41% |
| Beta blocker on discharge after AMI | 98% | 96% | 94% | 85% |
| Diabetes: HgbA1c done past year | 96% | 87% | 89% | 76% |
| Diabetes: Poor control HbA1c > 9.0% (lower is better) | 17% | 31% | 23% | 49% |
| Diabetes: Cholesterol (LDL-C) Screening | 95% | 91% | 94% | 80% |
| Diabetes: Cholesterol (LDL-C) controlled (<100)  | 60% | 40% | 48% | 31% |
| Diabetes: Cholesterol (LDL-C) controlled (<130)  | 82% | 65% | 71% | 51% |
| Diabetes: Eye Exam   | 79% | 51% | 67% | 45% |
| Diabetes: Renal Exam   | 66% | 52% | 59% | 47% |
| Hypertension: BP <= 140/90 most recent visit  | 77% | 67% | 65% | 61% |
| Follow-up after Hospitalization for Mental Illness (30 days) | 70%(4) | 76% | 61% | 55% |
| Immunizations: influenza, (note patients age groups) (6) (7) | 75%                                 (65 and older or high risk) | 39%                                (50-64) | 75%
(65 and older) | 68%                                    (65 and older) |
| Immunizations: pneumococcal, (note patients age groups) (6)  | 89%                      (all ages at risk) | Not Reported | Not Reported | 65%                             (65 and older) |

## What Katrina Taught Us

- Data Warehouse
- VistA Web
- How ready we were?

## VA Patient Satisfaction

- 2000:  79 of 100 on external American Customer Satisfaction Index (U. of Michigan) Outpt Care
- 2001:  82/100 Inpatient & 83/100 Pharmacy
- 2002:  Repeat Performance - Outpt (79) & Inpt (81)
- 2003:  Repeat Performance - Outpt (80) & Inpt (81)
- 2004:  Repeat Performance – Outpt (83) & Inpt (84)
- 2005:  Repeat Performance -  Outpt (80) & Inpt (83)
- 2006:  Repeat Performance -  Outpt (82) & Inpt (84)
- Significantly better than private health sector in both categories, by 10 points for inpatient and 8 points for outpatient
- Loyalty Score of 94 percent for “veteran loyalty” and 91 percent and Customer Service, each one point increase over 2005

## Sharing VA’s Expertise 

- American Health Information Community (AHIC)
- Public-private collaboration to develop standards and increase interoperability of health information
- Health Information Technology Standards Panel (HITSP)
- Incorporated Consolidated Health Informatics initiative recommendations
- Develops implementation guides for identified health standards
- Certification Commission for Healthcare Information Technology (CCHIT)
- The Department of Defense/Military Health System's Armed Forces Health Longitudinal Technology Application
- WorldVistA EHR, an open-source system that runs in the hospitals and clinics in the Department of Veterans Affairs

**Notes:**
CHI
Federal interagency initiative to develop standards for interoperability of health care information
23 federal participants, including HHS, Dept of Defense, Indian Health Service, Food & Drug Admin, Centers for Disease Control & Prevention 
20 health data and communication standards adopted in Phase I; additional data domains in Phase II
Within VA:  domain-based implementation across VA systems

VOE
VA is collaborating with the Centers for Medicare and Medicaid Services (CMS) on a version of VistA/CPRS configured for physician office settings
Beta version released through qualified vendors
Will make the benefits of EHRs available to other providers
Could stimulate broader adoption & effective use of EHRs
PHR support to be incorporated

## Next Generation Strategy Overview

**Next Generation ****Strategy Overview**

- Moves from **facility-centric to person/data-centric**
- Uses national, person-focused health data repository for production & management/analysis/research
- Builds on, enhances & utilizes VistA
- Uses best, appropriate modern technology
- Programming, software, hardware, networking
- Standardizes data & communications
- Enhances interoperability among Federal & private health systems
- Expands current personal health record capabilities

## My HealtheVet 

- Internet-based, secure Personal Health Record
- Personalized health assessments
- Veterans can view, retain, and update their personal health data (e.g., BP, Blood Sugar, Weight)
- Comprehensive, personalized health education and information
- See medication names and order refills on line
- Fosters partnerships between patients, their providers, and their families to improve care
- Future updates include secure messaging, lab results available on-line and much more

## Standards & Terminology Services

**Veterans**** ****Health Administration**
**Office of Information **
**Health Data and Informatics**

- Marcia Insley
- Portfolio Management Officer
- Health Data Systems

## Definition

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

## Value of Standard Terminology

**Hines VAMC**

**Notes:**
Data standardization supports the exchange of data from system to system and more importantly assures that data retains the same meaning

## 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**** *

## 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 patient’s complete medical record
- To reduce costs by eliminating redundant expenses

**Notes:**
This project is important for the VHA, separate from external drivers or the HealtheVet Project.
Carnegie Mellon supported the importance of this project in their evaluation of VHA’s IT program.

## External Business Drivers for Data Standardization

**Federal Terminology Standards Initiatives**
- Consolidated Health Informatics (CHI) – the Federal interagency initiative to develop standards for interoperability of health care information
- HHS’s Healthcare Information Technology Standards Panel (HITSP) which has subsumed the work of CHI and is the current standard setting vehicle
**Clinical Data Repository/Health Data Repository (CHDR)**
- Congressionally mandated
- Supports interoperability between VA and DoD systems
- Decision support based on information from both agencies
- Deliverables for 4 domains:  Vitals, Outpatient Pharmacy, Allergies, and Lab

**Notes:**
The CHI work is being subsumed by HITSP-- Healthcare Information Technology Standards Panel (3/06)

## What Does Standardized, Interoperable Data Mean to the Veteran?

**Washington DC VAMC**

**Tampa VAMC**

**One Healthcare Record**

**Better Care**

**CHDR**
**LDSI**

## Domain Based Approach

_**Domain:**_**  a content area with related files, fields and code sets**
**E.g.:  Demographics, Allergies, Pharmacy, Laboratory**
_**Domain Action and Implementation Teams**_** (DATs and DITs) conduct the work of standardization for an assigned domain**

## Multi-disciplinary Domain Teams

- Project Managers
- Business Owners
- Program Office Officials
- Clinical Application Coordinators
- Subject Matter Experts
- Data Standardization Analysts
- Terminology Analysts
- Developers
- Architects
- Standards Development Organization representatives
- Implementation Managers

##  Standardization Process

**Analyze reference table data from sites**
**Research existing standards**
**Recommend data standards – approved by Health Data Systems Health Information System Executive Board**
**Establish an implementation plan**
**Create requirements documentation**
**Develop the standardization software**

##  Standardization Process

**Complete testing **
**Support implementation of data standards**
**Support data clean-up activities**
- Provide centralized mapping to standard terminology when necessary
**Maintain the standards**
**Monitor compliance**

## Critical Domain Decisions

- How much data do we standardize?
- Time forward vs historical
- Allergies – all data
- Vitals – time forward
- Laboratory – time forward
- Outpatient Pharmacy – non-inactive medications
- What is the impact on patient care?
- Order checks
- Maintain the integrity of the legal health record

**Notes:**
Legal Health Record Definition as noted in the VHA Handbook 1907.01 entitled Health Information Management and Health Records 
nn. Health Record. A health record includes the electronic medical record and the paper record, combined, and is also known as the legal health record. A health record can be comprised of two divisions, which are the: 
(1) Health Record. This is the documentation of all types of health care services provided to an individual, in any aspect of health care delivery. It includes individually identifiable data, in any medium, collected and directly used in and/or for documenting health care. The term includes records of care in any health-related setting used by health care professionals while providing patient care services, to review patient data or document their own observations, actions, or instructions. The health record includes all handwritten and computerized components of the documentation. 
(2) Administrative Record. This is an official record pertaining to the administrative aspects involved in the care of a patient, including demographics, eligibility, billing, correspondence, and other business-related aspects. 

## Critical Domain Decisions

- To what extent can we automate or standardize centrally?
- Cost
- Patient safety
- Accuracy
- Consistency

## Critical Domain Decisions

- What standard do we use?
- Is there a CHI/HITSP recommended standard?
- Is there a standard development organization with a published standard that will meet our need?
- Allergies – no CHI standard (CHI adopting VHA standard), coordinating with DoD
- Ingredients – FDA UNIIs
- Clinical Semantic Drugs – RxNorm
- Drug Classes – National Drug File (NDF)
- Reactions – VA/DoD subset mapped to SNOMED CT®
- Outpatient Pharmacy – NDF
- Problem List – ICD 9  SNOMED CT®
- Clinical Document Note Titles – LOINC® axes
- Laboratory Results Name – LOINC®
- Laboratory Results Content  – SNOMED CT®

**Notes:**
CHI – Consolidated Health Informatics
HITSP – Healthcare Information Technology Standards Panel 
LOINC – Logical Observation Identifier Names and Codes
SNOMED® CT – Systematized Nomenclature of Medicine Clinical Terms

## Critical Domain Decisions

- What could we “break” if we standardize this file or this field?
- Data relationships
- Processes
- Clinical Decision Support rules
- Clinical Reminders

##  Critical Domain Decisions 

- Mapping considerations
- Preference is to standardize a reference file without mapping
- Sometimes we must have a mapping strategy
- Mapping options:
- Local reference mapping
- Mapping of local terms to the standard
- Site responsible for the entry of centralized mapping into local system (Laboratory, Clinical Document Note Titles)
- Mediation mapping
- CHDR, SNOMED® CT, ICD-9, CPT
- Conversion mapping
- e.g., allergy free text mapped to standard terms
- SDO to SDO
- SNOMED to ICD-9; LOINC® to CPT

**Notes:**
Our preference is not to map if that’s possible.

Local Reference Mapping is defined as mapping of a local VistA file to a standard file.  The option should only be viable when absolutely necessary, e.g. implementation of standard terminology would create a risk to patient safety or be detrimental to processes at VA Medical Centers.  The DAT should clearly document any compelling reasons for choosing this option as apposed to standardization.  Both STS and the sites will have to commit considerable resources to accommodate local reference mapping as this is not a “one time” effort and requires verification, ongoing maintenance, and quality management.  

Conversion Mapping is the annotation of data with file to a coded standard value.  This effort requires use of the patch process rather than the typical STS deployment of standard terminology.  To date conversion mapping has been used in the allergy domain to clean-up free text allergens.  Conversion Mapping also incurs considerable resources.  Decision must be make if the cost to determine the mapping, create, and implement the change using the patch process outweighs  the benefits gained through minimizing risk in the form of patient safety.  

## Standardizing Terminology

- Unique identifiers are assigned to the standard terms
- Standard terms are added to the Enterprise Reference Terminology
- Contains Standards Development Organization (SDO) data such as ICD9, HCPCS, CPT
- Contains VHA-specific terminology (Vitals, NDF)
- Contains VHA extensions of standards
- Additional fields added to SDO data to support VistA package requirements

## Terminology Modeling

- Terminology Modeling – Standard terms are modeled
- VHA Terminology Model defines the structure of the terminology
- Terminology Model Style Guides contain both general and domain-specific business rules for data modeling

**Notes:**
Modeling clarifies the meaning and adds value to the standard – not just a list of terms

## VHA Terminology Model 

## Real World Example :Immunological Agents

## Real World Example :Methyl Salicylate

## Standardizing Terminology

- Standard terms are deployed to all VistA databases
- All databases contain the same terminology
- This is verified as part of the deployment process

## Accomplishments to Date

- Standardized Clinical Domains:
- Vitals
- Allergies
- Pharmacy Phase I
- Clinical Document Note Titles
- Orders (selected files dealing with order status and nature of order)
- Laboratory:  Chemistry & Hematology
- Over 200 administrative reference tables standardized

**Notes:**
Order status refers to whether or not an order is complete, discontinued, active, canceled, etc.
Nature of order refers to whether an order is verbally given, written, rejected, etc.

## Prior to Standardization:

**Now ****coded standard allergy terms**** that function in order checks**

## Laboratory Mapping

- Prior to standardization
- Very little use of LOINC® (approximately 35 tests nationally)
- Standardized to Logical Observation Identifiers Names and Codes (LOINC®) for chemistry and hematology result names
- Provides standard, universal list of lab result names and codes
- Allows comparison of results across systems
- 152,000 lab tests in Chemistry and Hematology now mapped to LOINC

## Prior to Standardization:Decentralized Note Titles

- 156,000 active and in-use note titles  2,452
- 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 were more than 1500 different titles for Infectious Disease Encounters alone
- Standardization now allows clinicians to quickly find relevant content

## Title Mapping Example

**Title Mapping Example**

- _HEART FAILURE_ _CLINIC_ _FIRST VISIT_ _NOTE_

***SUBJECT MATTER***
***DOMAIN***

***SETTING***

***SERVICE***

***DOCUMENT TYPE***

**Local Note Title**

**Standard Note Title**

- _CARDIOLOGY_ _OUTPATIENT_ _INITIAL EVALUATION_ _NOTE_

**Notes:**
2452 clear, succinct clinically relevant titles

## We’re Standardized ...Now What?

- Healthcare is not static...neither are standards
- Standard reference files are locked to local edit and maintained centrally or mapped to centralized standard and monitored for continued compliance
- Centralized maintenance process for locked files is called  “**New Term Rapid Turnaround” (NTRT)**

**Notes:**
After a domain has been standardized, free text and local additions to standardized reference files will no longer be permitted.  This makes it necessary to implement a process by which clinicians and others request additions to the national standard.  We refer to this process as New Term Rapid Turnaround or NTRT.

## Anyone can request a new term through NTRT Web site
Requests are reviewed by teams of subject matter experts who follow established business rules
Approved new terms are added to the national standard, then sent via HL7 messages to all 128 VistA databases, updating all sites simultaneously
Newly deployed terms are immediately available to end-users
The requester receives direct feedback on either acceptance or rejection via e-mail

- Requests are reviewed by teams of subject matter experts who follow established business rules
- Approved new terms are added to the national standard, then sent via HL7 messages to all 128 VistA databases, updating all sites simultaneously
- Newly deployed terms are immediately available to end-users
- The requester receives direct feedback on either acceptance or rejection via e-mail

**New Term Rapid Turnaround Process**

**Notes:**
The web site will be designed to collect the specific metadata necessary to add terms in that domain.
 If the term already exists or if there is a preferred term that should be used instead of the requested term, ERT will notify the user of the correct term to use.
The deployment process will be addressed later in the presentation.

## Domains in Progress

- Radiology
- Problem List
- Encounters
- Immunizations
- Microbiology & Anatomic Pathology
- Pharmacy Phase II
- Future domains prioritized by business community

## Slide 63

## Slide 64

## Slide 65