# Presentation: 659392

## August 24, 2004IHS Information Technology Conference

Robert M. Kolodner, MDActing Chief Health Informatics Officer &Acting Deputy CIO for Health

Veterans Health Administration
Department of Veterans Affairs

**Robert M. Kolodner, MD**Acting Chief Health Informatics Officer &Acting Deputy CIO for Health
**Veterans Health Administration**
**Department of Veterans Affairs**

- The Future of Health Information Technology  Health_***e***_People:*IHS & VHA**Moving Forward Together*

## Outline

**VA/VHA – Do you know what’s been going on?**
**Electronic Health Records EHR in VA (VHA)**
- VistA – current status
- Benefits to patient care
**Health**_***e***_**Vet – the Next Generation VistA**
- Why Change?
- What will Health_***e***_Vet-VistA look like?
**Standards & Personal Health Records**
- Brief highlights
**Health**_***e***_**People**
- Plans for IHS & VHA to work together on IT
- VHA’s commitment to Health_***e***_People and to IHS
**Implications for IHS and potential IHS benefits**

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## Alternate Outline

- Current VistA
- 	Health_***e***_Vet-VistA
- 		Health_***e***_People-VistA
***What does all this mean for IHS?***

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## 2004:  Who is “VA”?Veterans Health Administration

**Locations & Affiliations**
**  ****~ 1,300 Sites-of-Care **
- Including 158 medical centers, ~ 850 clinics, long-term care, domiciliaries, home-care programs
**  ****Affiliations with 107 Academic Health Systems**
- Additional 25,000 affiliated MD’s
- Almost 80,000 trainees each year
- 60% (70% MDs) US health professionals have some training in VA

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## 2004:  Who is “VA”?Veterans Health Administration

**Budget, Staff, & Patients **
-   **~193,000 Employees (~15,000 Doctors, 56,000 Nurses, ****      33,000 AHP)**
-  *6% decrease** since 1995 *
- 13,000 fewer employees than 1995
-   **~ $27.4 Billion budget **
-  *42% increase** since 1995 *
- Flat at ~ $19B from 1995 - 1999
**  ****5.1 million patients, ~ 7.5 million enrollees**
* **104% increase in patients treated** since 1995*
- From 2.5 million patients / enrollees in 1995

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## Changing Health Care Changing Workload in VA

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## Toward a “Virtual Health System”

**Electronic Health Records (EHRs) **
- Robust, Widespread Use of High Performance Electronic Health Records (EHRs)
**Standards**
- Health Data & Communication Standards
**Personal Health Records (PHRs)**
- Full copy of one’s own health information along with personalized services based on that information
**Health Information Exchange **
- Connectivity Among the EHRs, PHRs, and related health entities

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## EHRElectronic Health Record

**EHR****Electronic Health Record**

## DHCP

**D**ecentralized**H**ospital**C**omputer**P**rogram

**R**esource and**P**atient**M**anagement**S**ystem

**C**omposite**H**ealth**C**are**S**ystem

**DHCP ******** RPMS**

**DHCP ******** RPMS & CHCS**

**DHCP ******** RPMS & CHCS ******** VistA**

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## 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)”*_
**“****Using a digital medical record that follows veterans from one facility to another, the ****VHA has improved quality of care for patients**** while ****staying within a tight budget****.”**** **
*Wall Street Journal, July 15, 2002*

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## Praise for VistA – from Users

- 	“**...****frustration and disenchantment were widespread .... **Several well-known technology vendors were subjects of biting criticism by name. Satisfaction with systems (in some cases from the same vendors) tended to be expressed in less than gushing terms.”
- 	**“****But there was one notable outlier from the nexus of negativity; the Veterans Administration.  It received unwavering praise....”**
- Summary of results from almost 1600 respondents to a survey of American College of Physician Executives members regarding their organizations’ progress in implementing clinical information systems
- Most indicated that problems and ordeals continue
*The Physician Executive – March-April 2004*

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## Electronic Health Records (EHR) &Computerized Provider Order Entry (CPOE)

**100 % VA Medical Centers have Electronic Health Record**
**CPOE is one of the *****Leapfrog Group’s*****  “Top 3 Safety Strategies”**
**Outside of  VA, CPOE < 8% nationally**
_**<**_** 30% among Academic Medical Centers**
**Nationally, 93% of all VA Rx’s by CPOE**
**Ultimate Goal:  100% **
**VA is the Benchmark for CPOE**
**All VA Medical Centers also have Desktop Imaging**

***Electronic Health Records (EHR) &******Computerized Provider Order Entry (CPOE)***

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## Some National VistA Statistics (Total / Daily)

**Number of orders**
- 1.14 Billion / >860,000
**Number of Documents **(Progress Notes, Discharge Summaries, Reports)
- 533,000,000 / >510,000
**Number of Medications Administered with BCMA**
- 500,000,000 / >580,000
**Number of Images**
- 197,000,000 / ~340,000

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## Performance MeasurementSetting 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) |

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## Slide 15

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## Slide 16

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## Two-Way Exchange of IT Solutions Between IHS & VA

**VistA contains solutions “borrowed” from IHS**
- Health Summary
- Patient Care Encounter (PCE) from PCC
- File Manager 17
- Patient Merge
- Clinical Reminders (version 1)
- And more

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## In Summary

**VistA/CPRS was & is a success **
- Built by “fire” of VHA collaboration
- In the public domain; could be for future as well
- 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

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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
- Modernize & replace older systems
- Ensure documentation on application programs
- Move to modern technologies
- Increase flexibility to respond to future health needs
- Lower cost of maintenance
**Support our future health system**

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## Slide 20

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## Operational (Clinical) Drivers for Change

**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 and maximized function/health *(time to zero)*
- Inconvenience *(inconvenience to zero)*

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**Notes:**
The veteran perspective – 
receive care in the manner they want:  seamless, in the home, confidentially, no mistakes.
Improved health through improved healthcare systems.

## HealtheVet – Strategy Overview

**Health**_***e***_**Vet – ****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 **
- Moves from legacy VistA to Health_***e***_Vet-Vista
**Uses best, appropriate modern technology**
- Programming, software, hardware, networking
**Standardizes the “core” applications**
- Provides processes for local enhancements beyond the “core”
**Standardizes data & communications **

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## What is HealtheVet-VistA ?

***Health***_***e***_***Vet-VistA is the next generation of the existing VistA Legacy systems achieved by incrementally rehosting or reengineering current health & administrative information applications to operate using modern technologies.  ***
***Once Health***_***e***_***Vet-Vista is fully implemented, the VistA Legacy system will be retired.***

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## EHR – Beginning the Upgrade

**1****st**** JAVA code released**
- Health_***e***_Vet Desktop
- Care Management software (version 1)
-  Brand new type of functionality – in its infancy
-  “The baby needs time to grow” – VHA’s pattern of IT success over the past 20+ years
**On the verge of last release of CPRS (!!!!)**
- Code finished now
- Field release early in 2005
**To be replaced by CPRS-R (Rehost/Reengineer)**
- Begins migration from M(UMPS) & Delphi to JAVA & J2EE

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## EHR – VA’s Next Leap ForwardCPRS-R

**Scheduled for release in late Summer 2005**
**Sets the stage for modular enhancements & computable data from the HDR**
- New look and feel (evolution, not a disruptive change)
- View patient data from interim HDR (Remote Data View+)
- Drug-Drug & Drug-Allergy order checks on remote data
- Includes data from DoD
- View remote images attached to remote notes
**Initial rehosting with 4 follow-up phases**
- Clinical Documents
- Orders Management
- Clinical Decision Support
- Integration with the local and national HDR

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## Health Data Repository (HDR)
Domain-by-domain uploading to the national HDR as local VistA data is “cleaned” to align with new standards
Standardized (and computable) data from all VHA sites
Data “cleaning” will go back only a limited number of years (may vary by domain)
Older “non-standardized” data resides in HDR Historical
Remains available
Text form is the same as current Remote Data Views data
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)

- Domain-by-domain uploading to the national HDR as local VistA data is “cleaned” to align with new standards
- Standardized (and computable) data from all VHA sites
- Data “cleaning” will go back only a limited number of years (may vary by domain)
- Older “non-standardized” data resides in HDR Historical
- Remains available
- Text form is the same as current Remote Data Views data
- 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)

**EHR – VA’s Next Leap Forward****HDR**

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## 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

- 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

**EHR – VA’s Next Leap Forward****HDR**

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## VERY Simple Schematic

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## VERY Simple Schematic

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## VERY Simple Schematic

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## VERY Simple Schematic

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## VERY Simple Schematic

- Hospital or Clinic

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## VistA to HealtheVet (& HealtheVet-VistA)

**VistA Legacy (Maintenance/Enhancement until “Retirement”) [Current – 2005]**

**VistA Imaging**

**Fee****	**

**Billing**

**Pharmacy**

**Laboratory**

**Health Data Repository**

**Secure systems/infrastructure**

**Enterprise Architecture**
**Strong Project Management**

**....  2000  2001  2002  2003  2004  2005  2006  2007**

**High Performance Network/Infrastructure**

**Health**_***e***_**Vet-VistA**
**(Person/Data-Centric Next Generation VistA) (2005-  )**

**High Performance Workforce**

**Scheduling**

**VA-wide ****OneVA activities**

**VHA Health**_***e***_**Vet Activities**

**VistA to Health**_***e***_**Vet ****(& Health**_***e***_**Vet-VistA)**

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## HealtheVet-VistA box and oval schematic

**EHR**

**PHR**

**Standards**

**Information****Exchange**

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## Principles Guiding HealtheVet-VistA

**Commitment to remaining in the public domain for the “core” software ****– Open Source??**
- Scheduling, Pharmacy, Laboratory
- Management/financials used by VA may be all COTS
- Support linkage with COTS specialty products (e.g., ICU & Anesthesia Systems)
**Design maximizes vendor independence**
- JAVA/J2EE software to be use generic function, rather than proprietary extensions
- Support for “relational databases” and not just one database vendor
- Some estimates that ~20% of the software may use vendor (database) extensions for performance gains
**Uses Common Services Architecture**
- Enhancements often possible by improving a component or service rather than re-writing an entire application

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## Principles Guiding HealtheVet-VistA

**Phased migration from VistA to Health**_***e***_**Vet-VistA**
- Do not move from existing software until replacement is “solid” without loss of existing functionality
**“****Core” modules are standardized and “locked down”**
- Innovation from extensions around the core
- If “Open Source”, then opportunities for direct contributions by enhancing the core
**Adheres to Federally-adopted data and communications standards**

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## Standards

**Standards**

## Standards – Advances in the Federal Government

**SNOMED: Played key role in license negotiations & purchase **
- SNOMED now available at no cost to every health organization in the US
**CHI (Consolidated Health Informatics): Continued active leadership role – an eGov Initiative**
- Participants include VA, DoD, HHS, NIH, IHS, CDC, FDA
- CHI has endorsed data and communication standards in 20 domains
- Some recent domains: Anatomy, Demographics, Immunizations, Medications, Laboratory Test Order Names, Units
- Adoption of the same standards by all CHI participants, including DoD and IHS
- Beginning the implementation of these standards VA-wide

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## PHRPersonal Health Record

**PHR****Personal Health Record**

## Slide 40

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## What Is MHV?

**My Health**_***e***_**Vet**
- A new ***e***health portal where veterans, family, and clinicians may come together to optimize veterans’ health care
**Web technology **
- Will combine essential patient record information and online health resources to enable and encourage patient/clinician collaboration
**Veterans **
- Will be provided with information on benefits, services, and special programs, and can request services online

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**Notes:**
Bullet 	1 - for primary and specialty care for MTF enrolled population 
Bullet 2 - from direct care PCMs to specialists both in the direct care and network for medical appropriateness and 
Bullet 3 - (Case Management, Disease Management, Medical Management) for care delivered to MTF enrollees

## Principles:

- 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 Health_***e***_Vet system

**My Health**_***e***_**Vet (Phase 1) **
**Veterans Day 2003**** **

_**www.myhealth.va.gov**_

**Principles:**

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## Slide 43

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## Improved health & “paperless”

- 2001   2002   2003   2004   2005   2006  2007   2008   2009  2010

**Standards**
**Data**
**Communications**
- ---------------------
- Health Info Systems
**Electronic Health Records Systems (EHRs)**
- Personal Health Record Systems (PHRs)
- Info Exchange

**Improved**
**Health**
**Paperless (IOM)**

- Adoption by health organizations & persons of affordable, high quality & standards-based EHRs, PHRs & Health Info Exchange

**Improved health & “paperless”**

- * This graphic inspired by discussions at a Kaiser-Permanente and IOM sponsored meeting in October 2001.

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## HealthePeople Initiative:Toward a “Virtual Health System”

**EHRs – **
- Provide financial incentives
- Strongly encourage private sector vendors to make available affordable, high quality, standards-based EHRs
- Strongly encourage provider-based efforts like AAFP
- Continue to improve Health_***e***_People-VistA & make available
**Standards – **
- Consolidated Health Informatics as federal leadership
- Strongly encourage public/private development/adoption of national standards
**PHRs – **
- Strongly encourage public/private sector to work together to develop & make available PHRs for persons
**EHR/PHR Info Exchange (IE) – **
- Strongly encourage public & private sector to work together to develop & make available national “exchange” solution

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**EHR**

**PHR**

**Standards**

**Information****Exchange**

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## Recent 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 – April 27, 2004*

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## Support from VA Secretary Principi

**	****“****Because VA’s medical IT advances are in the public domain, our broad spectrum of solutions to health care’s challenges—from patient safety to real-time long-distance delivery of vital records and images—can be shared immediately with our partners in the private sector. ”**
*Secretary Principi – May 6, 2004*

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## HealthePeople –  Stimulating EHRs

**VA collaborating w/Centers for Medicare and Medicaid Services (CMS) **
-  Make the benefits of EHRs available to other providers
-  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
- Includes the addition of functionality for OB/GYN and Pediatrics, and of support for disease management
- Will be incorporated into core VistA & will reflect changes made in core VistA – only 1 version of VistA
- Expected release – early CY 2005

**VistA            Health**_***e***_**Vet-VistA            Health**_***e***_**People**

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## Opportunity for Long-Term PartnershipBetween IHS & VHA

**Opportunity for ****Long-Term Partnership****Between IHS & VHA**

## Implications of VistA Evolution

**Continued enhancement to core packages**
- Scheduling
- Pharmacy
- Laboratory
- Radiology
- Etc.
**Technology migration to JAVA and relational database**
**New major architecture features**
- HDR
- Person Service to replace MPI
- Component framework for graphical applications

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## Potential IHS Benefit

**Align with current VistA**
- Continue activities to incorporate long-standing IHS modifications into “off-the-shelf” VistA
- Collaborate on VistA - Office EHR to ensure that VistA addresses the essential generic EHR requirements
- Concentrate IHS investments on IHS-unique needs
**Participate actively in requirements definition for Health**_***e***_**Vet-VistA to ensure that Health**_***e***_**People-VistA meets IHS future needs**
**Leverage VA’s**
- significant investment to develop Health_***e***_Vet-VistA
- commitment to Health_***e***_People-VistA
**IHS / VHA Steering Committee as the inter-agency governance body ensuring continued collaboration**

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## Come Join Us As We Transform VistA & RPMS into HealtheVet-VistA and IHS’s Brand of HealthePeople

**Come Join Us As We Transform VistA & RPMS into Health**_***e***_**Vet-VistA and IHS’s Brand of Health**_***e***_**People**

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