**Transcript of Cyberseminar**

**Timely Topics of Interest**

**VistA Evolution Program Vision and Associated Knowledge Gaps**

**Presenters: Merry Ward, MS, PhD; Brenna Long, MS; Jonathan Nebeker, MD, MS**

**April 3, 2014**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact**merry.ward@va.gov*

*Moderator:*- for us today we have Dr. Merry Ward, the VistA Evolution Research and Development Manager.  We also Brenna Long joining her, VistA Evolution Program Specialist.  Finally we have Dr. Jonathan Nebeker joining.  He is the Associate Chief Medical Informatics Officer for VistA Evolution.  All three are part of the office of Informatics and Analytics.  At this time I’d like to turn it over to you.

*Merry Ward:*Hello, this is Merry Ward.  Our goal today is to provide you with an overview of our VistA Evolution Program to date, with a focus on the role of research and knowledge gaps.  We hope that an outcome of this will be for you to engage us as you develop your research.  Jonathan, Brenna, and I are in the Office of Health Solutions Management.  It’s a new name, originally IEHR.  It’s led by Dr. Paul Nichol.  The Health Solutions Management is in the Health Informatics Office led by Dr. Terry Cullen.  HI is in the VHA Program Office, the Office of Informatics and Analytics, better known as OIA, led by Ms. Gail Graham.

I’m Merry Ward.  I’m the VistA Evolution Research and Development Manager.  Brenna is the VistA Evolution Associate VHA Program Manager, which is a new title, and Jonathan is the Associate Chief Medical Informatics Officer.  All three of us have history and origins in the VHA research program, specifically HSR&D, so we understand the importance and potential of research and science.  In fact, you will find the entire VistA Evolution Program open and eager to engage scientists.  I’d like to find out who you are.

*Moderator:*Thank you, Merry.  For our audience members, I’m going to go ahead and put up a slide for you.  Go ahead and select the circle next to the option that best describes your role.  We’ll wait for those responses to come in.  Wow.  Very receptive group.  Looks we’ve already got about a 75 percent response rate.  We’ll give people a little bit more time.  Where do you work, are you a VHA employee, VA OI&T, VHA contractor, Federal employee but non VA, or non-federal.  It looks like we’ve got just about 100 percent response rate.  Three quarters of our audience are VHA employees.  About five percent are VA OI&T.  Seventeen percent VA contractors, and we have about five percent that are non-federal.  Thank you to our respondents.

*Merry Ward:*Okay.  Thank you very much.  It’s an interesting group.  Our objectives for this program presentation—if you could move the next slide, please?

*Moderator:*Merry, if you’d like to advance them yourself, you’re welcome to.

*Merry Ward:*Oh, okay.

*Moderator:*Just down in the lower left-hand corner, press the right-facing arrow.

*Merry Ward:*Okay.  Got it.  Our objectives today are to share our vision for the VistA Evolution program and to play for next generation VistA/CPRS, essentially.  We want to share our own knowledge gaps, and to engage the Health Services Research community, and the research community at large in VistA Evolution.  Today I’m going to start by just talking about research in general in VistA Evolution.  Jonathan is going to then present the VistA Evolution program, and some of his thoughts about research gaps.  Brenna’s going to talk about the program structure.  I’d like to know about your role in VA and what kind of work that you do, so if you could take a minute and answer this poll.  Choose all that apply, please, in this case.

*Moderator:*Do you have roles as a health care provider, a research/scientist, a VA central office program office, and informatics researcher, or none of the above?  I imagine many in our group wear many different hats.

*Merry Ward:*It’s interesting that a few of you are none of the above.

*Moderator:*Quite a bit, actually.

*Merry Ward:*It will be interesting to find a poll at the end, to find out what they do and who they are.

*Moderator:*Actually, people will have that option.  We’ll put up a feedback survey at the end and people can write in their specific roll.  All right.  I’m going to go ahead and close out the poll.  It looks like most of the responses have come in, about 17 percent health care provider, 28, research/scientist, 22, from central office program offices, 15, informatics, and about 42 percent say none of the above.  Thank you.  

*Merry Ward:*Okay.  Interesting.  My job here in research in VistA Evolution, is to bring research science and evidence into our program and development processes.  Second, it’s to push out our questions, gaps, and processes to researcher scientists.  Basically I’d like for you to see me as an open gateway, because we view your roles as critical to what we do here in VistA Evolution.  What we’re doing at VistA Evolution is evolving our great veteran record system toward a health management system.  We have data galore, decades of millions, decades of date for millions of veterans, and making meaningful use of these data is hard.  It’s hard on two levels—managing care for individuals, and figuring out how to build HIT systems to manage care.  

That’s where the individual care records with complex conditions may have thousands of clinical documents, and much structured data.  Just finding the right document can be a challenge.  We all know that integrating large amounts of data across time and conditions just to figure out what’s going on with the veteran can be challenging.  Just looking for the right tool on Amazon.com can be a challenge.  There’s lots of data available, but how do you use it?  There they care deeply about how—for us to use Amazon.com.

Anyway, figuring out how to develop HIT systems to facilitate something as complex as healthcare requires thought, knowledge, and understanding.  This is hard on two levels.  Let’s think for a minute about, as we move forward with developing our system, let’s recall the lessons of CPRA, reminders and alert.  Intuitively they made sense, right?  What could go wrong, we asked.  Just create a reminder or an alert.  We now know they distract and fatigue, and that they’re a source of a very disruptive emotion, annoyance.  Are they a safety risk?  Well, yeah.  We want to build new HIT systems beyond this intuitive appeal of things like reminders and alerts.  We want to develop systems based upon pathways of empirical knowledge and understanding.

We want to apply the best science, the best science of cognition, human factors, knowledge, and data.  We all know that performing from bodies of evidence based on scientific pathways is fundamental to healthcare.  This is nothing new.  Somehow we need to get our hands wrapped around that concept.  One of our own researchers, Charlene Weir out of Salt Lake, contracted early models of clinical decision support, which was focused on the decision itself, to more current models of cognitive science, which are about improving our thinking about information, improving our thinking about integrating information.  

Our current models suggest it’s the process we need to facilitate, not the decision.  What does this mean for you?  Unfortunately for researchers in developing your research models, it means going out and reading and keeping up with cognitive and social science.  It could be unfortunate at the beginning but I think you’ll find it pretty exciting.  It may also mean learning who the experts are in systems interfaces when you think about health information exchange.  For example, what does it mean for two systems to exchange information?  Are there any evidence-based models out there in business and banking, airline industries?  How can apply those well-documented evidence models to healthcare?

It may also mean your becoming familiar with a new field of data science.  I took a course last summer through Course Era in data science.  It was amazing and it wasn’t what I expected.  I now know that data science is a lot more than I ever thought it was.  It’s a pretty exciting field.  Because in there is fields like data visualization.  There’s the science of modeling or visualizing data for large ends.  We see that all the time.  What about science and experts who are experts in “N of 1” data visualizations, which is what we would want to look at with individual patients.  

The last point on this slide here is I’d like for us to think more deeply about how to use the HIT system itself and its associated data to develop novel and efficient approaches to developing the HIT system.  How do conduct health information technology for system surveillance, learning knowledge management, best practice management, maintenance, as well as how do we apply this system to determine the efficacy effectiveness and safety of the widgets we’re using.  There’s just a lot of exciting, interesting questions we could be asking, and we could be thinking about different ways of using the system.  

Jonathan, when we get to his presentation, he’s going to be talking about one of the models he’s been developing.  Of course, this is not—we haven’t foreclosed on just one model.   There are many models.  We just want them to be evidence based.  

What is the role of research in this evolution?  We want to drive this evolution program with forward thinking, visionary research.  We want to apply theoretical social and cognitive models to informatics development.  We want to fill our knowledge gaps with empirical knowledge.  We want to elucidate knowledge gaps.  What I’d like for you to do here is stay in contact with me.  I work from home and I’m very flexible.  I can talk to you any time of the day.  In fact I look forward to outside communication.  I’m a virtual employee.

You can also join the new list serve.  As of right now there’s no information there but I want you to join because we’re going to start using this to share information with you, and for you to share information with us, and to develop collaboration across all of you.  I’d also welcome research teams, centers, COINs and the like to contact me and we could have a seminar or a session, or whatever to develop your program.  I’m very open and eager to work with you.  I’m going to turn this over to Jonathan who’s going to tell us about the VistA Evolution Program.  Thank you.  Jonathan?

*Jonathan Nebeker:*Thanks.  Yep.  I’m just going to get the mute button working.  I think there’s another poll here before I start talking.

*Moderator:*We’re asking about your experience with VistA Evolution.  Please select one.  You have not heard of VistA Evolution Program until you saw this cyberseminar.  Had heard of it but I’m not very familiar with it.  Have prior understanding of the VistA Evolution Program.  Have engaged with VistA Evolution or VistA Evolution Program development.  It looks like we’ve got a wide selection across the group.  About 30 percent have not heard of it until today.  Thirty-five percent have heard of it but are not familiar.  Twenty percent have a prior understanding.  About 13 percent engage with VistA Evolution or VistA Evolution Program development.  We’ve got a wide range.  Thank you.

*Jonathan Nebeker:*All right.  There’s a few concepts here I want that we need to make sure that people don’t get confused on, because there has been confusion over the last several months about some of these concepts.  VistA Evolution’s program, it’s a joint program between OIT and VHA.  There’s a distinction between the program and the product.  VistA Evolution is the name of the program.  That will cover iterations of VistA.  The VistA Evolution product is—currently we’re calling that VistA 4.  People, other than me, came up with that name.  You can see on the right-hand side of the slide that the first version of VistA was DHCP.  The second was when that was upgraded to include CPRS.  The third is the Gold Disk version of this, which came out last year.  Now we’re working on VistA 4, which is the next evolution, which is going to more of an open, not exclusively M-based or mumps-based system that will base open standards and also open source, and commercial software.  Again, VistA Evolution, the program VistA 4 is a product.

The main goal of this is to improve the value of healthcare.  That includes health care equity for veterans so they can come in to the VA and get improved care, as well as increasing satisfaction of providers as well as patients, increasing safety, increasing quality, and increasing efficiency, and also decreasing costs.  The mantra here is team-based, patient-centered, quality-driven healthcare.  As many of you know, our current systems are not really designed to address any of these areas very well.  I’ll just walk though these a little bit.

For team-based, we hope to have one shared care plan that everybody can modify and work on, including the patient.  Task- and goal-based communications and getting away from open-ended informational communications that take certainly a large proportion of provider time, maybe up to half-an-hour a day just to understand when you don’t need to respond to communication.  Distribute decision making, including the patient population management.  I’ll talk a little bit more about that for the research community.  

Patient-centeredness, we want to make sure we can get goals and preferences of the patient clearly in the record and link interventions to that, and have increased patients’ participation in the plan.  Also working my Healthy Vet program and the connected health program to involve the patient.

Quality-driven.  We want to be able to get to better visibility on outcomes and link-type management.  I’ll talk more about that below. 

Here’s a schematic.  One thing that’s important to understand, especially for the research community to understand, is inter-operability is the number one congressional, and probably the number one presidential White House priority for the VistA Evolution Program, at least for VistA 4 product, that’s sort of in the middle of this graphic.  We want to have inter-operability with Veterans Benefits, because many people are aware of the backlog in benefits that’s been featured on John Stewart a few times, and how we need to still get through those so veterans can get help and be seen in the VA and get their pensions and disability payments as soon as possible.  Getting data from the Department of Defense on their service members and the care that they’re having in military treatment facilities.  Also working with community partners, such as Kaiser or your local healthcare systems, to get their date in so we can operate on that.

We have a three-tiered architecture that’s made tangents or reference to, and so we have the front end GUI, the middle—which has a lot of applications that do stuff for us.  This is where so many people think of an application’s what you have on a desktop, but we think of applications and service is what you have in the middle that do stuff.  Some of this stuff is helping with care plans.  That all sits on a standardized data model.  I’m not going to go over any architecture any further.  If that interests you we can coordinate with you on that.

This is the road map.  I wonder what this is?  Oh, yeah, this is a road map we just submitted to Congress.  Well, actually it’s a road map we submitted to Congress a couple of weeks ago.  This is a graphic that we’re in the process of submitting to  Congress.  I wanted to put this in here because it’s important for people to understand the view that Congress has, and the White House, of what we’re doing.  These are the years that we’re rolling this out over.  Some people may notice that we now have a new year in here, 2018.  This has been negotiated with Secretary Shinseki. He actually was one of the impetuses for changing this to 2018, because of our delayed funding from Congress and other reasons of delay that are outside of our control.

In 2014, at the end of this year, we’ll have two user interfaces, both in front legacy viewer, and with the help with Informatics Initiatives been working on, so a little bit more about that, at at least two sites.  Each of these also has more deployments, but that’s not part of package for the VistA Evolution road map.  There’ll also be some back-end work to enable intake of standardized data, and also standardized packages across the VA so that we can build on a common platform, instead of having all the local iterations.  

In 2015—so that’s interesting—we probably need to change that header a little bit.  This is for meaningful use and the core of care management.  We have promised the White House that we will achieve ONC certification of our technologies and deploy that to at least a couple of sites.  This involves all sorts of stuff the VA clinicians have been asking for a long time.  Improve physician support, and also some population health management.  We will also deploy a new viewer that we plan on replacing VistA web with.  It’ll be much more user friendly and have some additional capabilities for you.  

In 2016, the focus here is on interoperability.  This is a statutory requirement.  That’s why we have it in the title of the deliverable.  The actual language from the law is in the first little bullet there—meaningful, real-time exchange of information.  We’ll also continue to build up the clinical functionality and start a deployment of Laboratory Information System at other sites.

2017 and 2018 is where we start to roll out the really—at the end of ‘16, ‘17, and ’18, we’ll start rolling out important clinical capabilities that support care management and patient-aligned care teams.  I’m not going to go really further into these.  We’ll illustrate those with examples to follow.  

This is an—we walk through some features of the health management platform.  The new features that will be available through clinicians through this platform are medication review info buttons and search.  This is an example of medication review, where you see that we have a medication such as ascorbic acid.  There’s some alerts we need to get taken care of with that.  It tells what the medication is, and then it gives a little graphic about the fills for that medication, whether there may need to be some extra fills for the future.  Oh, I see what I have to do.  Okay.  

When you drill down—this is not what the user interface looks like but I didn’t want to clutter up the screen.  When you drill down into one of these medications you have links for, and go out and click on these, and it will take you to a link and up to date what’s that’s relative to ascorbic acid, or to Micromedex, just a general Micromedex search that you can enter whatever you want in there, or a Micromedex search particular to ascorbic acid.  These info buttons are very nice.  They can be attached to problems, medication, and laboratory results, and give people much quick access to information about those items.

If we typed in “glucose,” this is an example of what would be returned.  You can that there is all these different—it looks like structured data as well as unstructured data, and returns results on what you might want to look at there.  Again, this is not how the whole user interface works.  I just was pulling out the key parts for illustration.

This is a general overview of the VA support product.  We really want to support care coordination, which is the patient-centered, team-based, quality-driven care.  We’ll have a new user experience.  There’ll be a more modern browser, initially browser deployed.  We’ll look at—as the platforms advance we’ll look at native rich-client applications.  We’ll include lots of improvements—and I see we have people from both pharmacy and radiology on the call here—improvements to both of these.  I won’t be focusing so much on these.  You can see a little bit that, down below where we have radiology protocols to help people—help radiologists decide what’s the most appropriate protocol.  We’ll also secure messaging.  

We’ll be eventually integrated within the EHR instead of a separate application, so that you can do the communications with patients in your workflow.  We also have VBA facilities, such as annotation, so that people can markup evidence of disability in the chart and have that for auditing as well as machine annotation, similar to search, where if you want to look for particular concepts or evidence for conditions that, with natural language processing other systems, the machine will markup things for you and show you where you might want to find relative information.

There’s other improvements here, and I won’t go into those anything further.  One big area that’s important for HSR&D providers—I didn’t recognize a lot of people from the list who are in this area—but we need help—what’s here, this is coming right out of our standard documentation here—what we really need help with from the research community is developing important metrics that help us address all these different dimensions, and that can be responsive to the EHR.  The problem is we can get the granular process level metrics about what the EHR might help with, but getting the quality metrics from the EHR is a little bit trickier.  It’d be a great area.  There’s lots of research that’s needed to help us get the right metrics that show the value of the EHR improvements.

Here I’m going to be going to another of decision and cognitive support.  This is a notional, semantic web or logic model of key clinical concerns.  The way this works you have interventions, health concerns or problems, observations—which is quantifiable observations—and goals.  There’s the subject/relationship predicate here, triple relationship where interventions may ameliorate, exacerbate, or cause some problem, which may manifest as an observation.  Glucocorticoids may cause diabetes, which manifests as increased serum blood glucose.  Our goal would be to control the—wow, what happened, Molly?

*Moderator:*I’m not sure, if any of other presenters are touching the screen, please don’t while Jonathan’s talking.  *[Laughter]*.  Thank you.

*Merry Ward:*That would be me, sorry.

*Jonathan Nebeker:*You can see how—and there recursive relationships here.  I am not going to walk through the whole thing.  Basically this is how we think clinicians think.  We have a little bit of evidence on this.  These concepts need to be really elaborated.  The goal—there’s almost no research in goals and linking goals to other clinical information this way, so it’s a area that we’re very interested in getting help from the research community.

This is an interesting rendition of—it left out some of graphic here, I guess because I had transparencies—but this shows how this applies in practice where you click on hypertension and it shows you the interventions related to hypertension, the observations that are related to hypertensions, and some of the patient goals that relate to that as well.  We also just have longitudinal display of information.  

This has been—we’ve done not on the exact—what I showed you there was just a screen paint of the initial design documents.  We have a better looking, actually, prototype in practice that we did a randomized control with a CPRS, very close CPRS mockup.  As you can see we saved both time, and we also increased the accuracy of diagnoses of what was going on with the patient, with the odds ratio of two for the increase in the accuracy, and an overall savings of 18 seconds, but we got up to about 40 seconds savings when we had—people were distracted by some other problem.  It’s easier to focus on all the problems of interest, so that’s a saliency condition.  Also, when they were interrupted in the context of dealing with a patient that had—actually when they were interrupted in their care they also had big savings in time.  They’re able to re-orient more quickly to the work that they were doing.  That’s encouraging.  We’d like to do more of these types of studies and investigations to make sure that we’re delivering evidenced-based informatics support.

Now I want to shift gears a little bit.  Another big area we’d like help from the research community is activity management and lean quality improvement—or lean-like quality improvement.  What I have here is—you can’t read it—is one of the older blood pressure algorithms.  This algorithm tells us what we have to do in what order, but it doesn’t tell us much—it’s really hard to operationalize.  It’s a big problem with clinical algorithms in the past.  They’re not explicit enough really to use, and to provide reproducible results when applied.  What we want to be able to do is try to get these—and then also when you get a million of these algorithms, like three, there’s always conflicts.  We hope that goals and goal preferences will help resolve conflicts among various algorithms.  

What we want to get to is away from these more general algorithms and operationalize these in this construct here.  This is sort of a business process management flow diagram, but not exactly.  What it does try to do is illustrate the—so the physicians is the second line down, the patient’s the top line, the nurses are the line below the physician.  There’s a clinical pharmacist below that.  Then there’s the dispense pharmacist and the phlebotomist.  Basically it shows how the roles of all these individuals are related.  We have transactional communication, so task-based communications or orders—they don’t only have to be orders.  They can just be requests to respond to information requests to do things as we’re going across the swim lanes of the various roles.  

The goal of the illustration here is the operationalization of the algorithm and then also the use of transactional or task-based communications to make explicit—to be able to order anything from anybody to anybody anywhere.  This all gets compiled into this diagram here for clinicians, where we might sort on condition or health concern and we can get all the interventions that are going on, and who’s responsible for them, and how they’re supposed to happen over time.  More on the right-hand side a task list for the provider for an individual patient, and also for all patients over the day.  This is very notional.  For some reason the notional marking got removed from these slides.  I’m not sure why that happened.

In summary, this is what we need help with.  We need help with metrics or key performance indicators, and to work with product effectiveness—that’s Jennifer Ford in our office—on those to help us refine those and get at responsive metrics to EHR interventions or changes.

In decision and cognitive support, we need lots of help here.  I see that some people from our OIA human factors group are on the line here, and also so researchers in that area.  There’s all sorts of ways that we’re looking for you to help, both with general theory development, theory translation, theories extensions, and then content development.

Also help with both decision support, which is sort of like decisions sciences, and cognitive support, which is psychology and human factors, to get us to help fill out the utilities, the features of our system.

Finally, activity management.  Looks like I didn’t quite finish this bullet, which includes N of 1 trials, to help us work through this lean quality management.  My metaphor is for Toyota.  They have this Toyota production model for lean management.  Our current medical information systems support the level—the analogous method is if you were to make a note at three or four stages of a production line about what was going on, just write a free-text note about that, and maybe take some measurements of the bolts that were going into the car, that’s the level of detail that we have with process characterization now in medicine.  Our hope is to get to a type of transactionally gathered information, where we can have much better visibility to an explicit level the variation of care that’s occurring so we can tease out what works and what doesn’t work.

That is all I have.  Hand it over to Brenna.

*Brenna Long:*Okay.  Can you hear me okay?

*Moderator:*Yeah.

*Brenna Long:*Good afternoon.  My name’s Brenna Long.  I’m going talk about the VistA Evolution Program structure.  Those of us with a research background know and are pretty comfortable with the idea that innovations are best fostered in a structure that balances flexibility with stability, or what you may call chaos and order.  With that said, the program structure is still emerging.  We’re currently very agile, meaning we’re kind of responding to the needs without any prescribed structure and process in place.  We’re accomplishing our goals through engagement with the stakeholders.  That’s part of the reason why we’re here today.  If you want to remain engaged I would encourage you to follow our collaboration site, reach out to myself directly or Jonathan and Merry, so we will continue to bring you in.  

And then for the next part, recognizing that we will have to operate within some less than agile constraints, we do want—the goal is to deliver products that are responsive, so we are going to be using a feature-driven process, with lots of design upfront, so I just think this is a good place to get the research community involved.  I think I probably need to back up to—in my slides.  Again, if you need to reach out to us we’ve got our contact here.  We’ve got SharePoint’s.  We have a collaboration space on Forum for Us, which was down for a few days but is actually back up.  That’s probably one of the best places for the research community to stay active.  That’s it for me.

*Moderator:*Great.  Thank you all very much.  With that we would like to open it up to the audience for any questions or comments you may have.  I know that a lot of you joined us after the top of the hour.  I would like to instruct you that you should be using the Q&A box located in the upper right-hand corner to submit any questions or comments for the presenters that you may have.  While we wait for those to come in, do you any of you have any more comments you’d like to make or any concluding thoughts?

*Merry Ward:*I think the possibilities here are incredible, to improve healthcare, and improve health in general.  We welcome your participation.

*Moderator:*Thank you, Merry.  Jonathan, I did see some slides at the end, some extra ones.  Was that anything you wanted to touch on?

*Jonathan Nebeker:*No, that was not.  If people want to download those it provides a little more information for them.

*Moderator:*Okay.  Great.  The first question that has come in—“I am currently working on a VA innovation competition project on family history in CPRS.  Is there anything being currently developed regarding collection of family history information on CPRS?”

*Jonathan Nebeker:*Brenna, do you want to take that?

*Brenna Long:*Family history is actually going to be part of project 15.  The *[inaudible]* at two, which is ’15, since it’s a ONC certification criteria.  I think it would be great to—I mean we can connect offline if you just want to reach out to maybe myself, or any one of us really, but probably myself is the best place for coordination.

*Moderator:*Excellent.  Thank you for that response and for *[cross talk]*

*Jonathan Nebeker:*just want to emphasize here.  This is one of—so people want to look up ONC certification, which includes medication reconciliation.  This is an opportunity to get research product into VistA 4 by the end—within 18 months.  There’s an 18-month deployment, so it’s very important to get involved now.  Also, you’ll see the rewards of your research or your input being displayed there.  You will also have opportunity for evaluation-type research with ONC certification criteria.  I’d go out to the web and find that and see if your stuff is relevant.

*Moderator:*Great.  Thank you both for those replies.  We do have some people wondering about if these slides will be made available.  Yes, you do have a reminder email that you received a couple of hours ago that has a link leading to them, and they will be available in our online catalog.  The next question—“We have developed specialized tools, for example, for HepC management.  How will those new tools fit in?”

*Jonathan Nebeker:*All right.  I’ll take that.  For disease management, we hope to work this into the framework, this activity management framework that I displayed.  We hope to make a framework that’s generic enough for most types of care plan and disease management and care coordination to fit into this framework.  Then there’s a population management component.  For the first set of this related features or work flows that might be related to hepatitis C management as a specialty work flow, we’d be interesting in using your use case as a way of validating what we’re trying to put together.  Specialty work flows will be deployed at the earliest in 2016, and more likely in 2017 and ’18 for the bulk of these.  The conceptual work and in your working with us develop the conceptual underpinnings of these, would be greatly appreciated.  Now on a population health management we are going to be putting in a capability to display user interfaces that are driven off the CDW, and from VINCI or other similar environments, into the display that the providers will see for population health management and some panel management activities.  This’ll be another way to get—and it’ll be relatively—it’ll be loosely controlled relative to the other interfaces.  This’ll be a way of getting stuff out faster.

*Moderator:*Thank you for that reply, Jonathan.  We do have several more excellent pending questions, so we will get to these.  The next one, “I have some measures important for geriatrics.  Who would I contact for potential inclusion?”

*[Crosstalk]*

*Jonathan Nebeker:*If they’re measures that show the benefit of the system, then Linda Wedemeyer is the appropriate contact.  Brenna or Merry can help set you up with that person.  I would actually recommend going through Merry.  If they’re measures for what you collect during your visit to quantify the patient in some way, then that would probably go into backlog of requirements.  Backlog’s not a bad word, but it’s something that we’ll get to deploying in the 2016 timeframe.  I think we can link you up now with the appropriate people to get a placeholder for your work.

*Moderator:*Thank you.  The next question we have, “Do you have any advice on how to get involved now in activities such as Med Rec, given that it can take one or more years to apply and obtain research funds?”

*Jonathan Nebeker:*Brenna, if you want to take that, you can, otherwise I will.

*Brenna Long:*I can’t respond to the research funds part.  I guess it depends on what type of engagement you want to do.  We are—again, Med Rec has to be done in ’15 according to criteria.  Maureen Layden, if you’re not already connected with her, is leading a lot of this work.  We’re starting to coordinate pretty intensely with the group as well, as well as the EHMP group, since it will be done in there interface.  This working group is starting to come together now.  Again, I guess if you want to reach out to me.  Just a general point I want to make for people that either have something that will be done in the short-term or something that will be in the backlog, I really do encourage you to follow, to join the Forums for Us and follow VistA Evolution’s homepage, because then you can at least see what’s going on and know when to jump in.

*Jonathan Nebeker:*Again, I just reinforce that if you’re a researcher and you’re contacting us, please copy Merry Ward in the communication so that she can ensure that your questions or you intentions are both facilitated and interpreted correctly.

*Moderator:*Thank you.  This is a follow-up to the geriatrics question.  “Who should I contact for patient-specific measures?”

*Jonathan Nebeker:*That would be—I think Brenna’s the right contact here.  It’ll go into the general category of specialty workloads.

*Moderator:*Thank you.  We’ve got some more great questions pending.  “How will the usability requirements for meaningful use be incorporated into the work of VistA Evolution?

*Brenna Long: [Laughter]*.  It’s also part of ONC certification, is to have user-centered design process.  We are engaging—I think we’re probably engaging those groups now as well.

*Jonathan Nebeker:*I missed the first part of the question.  Did we answer it?

*Moderator:*Let me see if I can pull it back.  One second here.

*Jonathan Nebeker:*While you find that out.  We’re setting up basically a group led by Stephanie Klepacki, K-L-E-P-A-C-K-I, I think, who is the overall sort of guru for meaningful use.  We are making sure that we’re hitting through all the various programs and development efforts and acquisition efforts that we have, that we’re addressing meaningful use criteria.  That’s how we’re managing it.  If you want to generally address meaningful use—first of all it’s technology, so it’s certification.  It’s not about the use.  It’s just about having the capability and the technology.  Later on we may—we have not yet committed to meaningful use demonstration.  We may do that, but it will be in ’16 or beyond.

*Moderator:*Thank you for that reply.  

*[Cross talk]*

*Moderator:*Oh, go ahead.

*Brenna Long:*I was just saying if there’s someone who wants to be part of the—participate in that, again, you can reach out to me and I can put you in contact with the group that’s forming for that now.

*Moderator:*Great.  Thank you.  I will just ask that if the attendee needs any further clarification they’re more than welcome to write back in.  The next question, “Do you view research opportunities as limited to VA employees?  If not, who is the best contact for external researchers?”

*Merry Ward:*This is Merry Ward.  Please contact me.  We are eager to engage VA and non-VA researchers alike.  We can talk about how to go about that on a case-by-case basis.

*Moderator:*Thank you.  All right.  The next question, “Will responses from the new VistA be available in the health factors data?  If not, where?”

*Merry Ward:*That’s an interesting question for this group, to ask this group.  I’m not sure of the answer, and that we would be able to answer that question.

*Jonathan Nebeker:*I think it can.  It’s not yet decide yet where new data will go.  There’s a preference that goes back in the VistA M database.  We plan on not making use of health factors.  In fact, we’ll probably migrate health factors to their own data fields in either the M database or another database that—the technology decision of exactly where this is going has not been made.  The key message here is we’re trying to go to standards-based, structured data and much is appropriate.  Having dedicated data fields for a lot of the stuff that health factors is doing.

*Moderator:*Thank you for that reply.  We do have some more questions and we’re going to continue on with them.  While doing so I’m going to put up the feedback survey for our attendees.  Please take some time to fill out these brief survey questions.  It is your opinions that help guide what we sessions we do offer in our program.  The next question have, “On slide 16, it mentions quote “joint legacy viewer.”  What is this?”

*Jonathan Nebeker:*A joint legacy viewer is was formerly called JANICE.  It is a Java-based, browser-based, frontend that has widgets that—like for laboratories or pharmacy or notes.  You can mix and match these widgets on one page and make your custom tabs.  This is available at select centers now.  It will be deployed to over 60 centers by the end of this fiscal year.  If you have further questions about that I’d suggest, again, copying Brenna and we can hook you up with that team.  The appropriate contact for that team is probably going to be Rachel Wiebe, W-I-E-B-E. 

*Brenna Long:*We also have a pretty good page built on the Forum for Us community.  You can watch the training videos.  

*Jonathan Nebeker:*It’s also on YouTube, too.  If you just look for JANICE or joint legacy viewer on YouTube, there’s one there.

*Moderator:*Great.  Thank you both for those replies.  The next question, “Are there plans for evaluation of the new system?  Who is involved in that?”

*Jonathan Nebeker:*There are no good plans at this point, other than these key performance indicators that I described.  Those plans, for cost effectiveness led by Jennifer Ford and her group, out of Quality, Safety, and Value, under Caroline Clancy is the lead for that.  For research-grade evaluation, we know of no current plans for that.

*Moderator:*Thank you for that reply.  “One of Jonathan’s final slides stated that he is looking for simulation help.  What kind of simulation activity were you envisioning?

*Jonathan Nebeker:*This is “If I increase the spironolactone, how is that going to affect the blood pressure and potassium?”  This is a really crude level.  More advance simulation is, this is how we even kind of simulate the patient, we’re making these recommendations based on how we think, based on the patient’s current profile for goals, interventions, conditions, etc.

*Moderator:*Thank you.  That is the final pending question—

*Jonathan Nebeker:*There’s actually another aspect to simulation that I think’s important.  In cognitive psychology, it’s important that the layout of the user interface actually helps people build a model of the patient in their brain, so they can perform their own simulation.  This is another area of important research that really has been missing from the medical informatics literature.

*Moderator:*Thank you for that.  That is the final question we had pending.  Would any of you like to give any concluding comments, final thoughts?

*Jonathan Nebeker:*just like to thank you all for attending.  Merry Ward, do you want to wrap us up?

*Merry Ward:*Yes.  I want to thank everyone for their—those were great questions.  Obviously were really engaged.  I look forward to further engagement.  Please contact us.  I see a lot of you have asked to join the list serve.  You should be approved shortly.  I look forward to staying in touch with you.  Thank you.

*Moderator:*Great.  I would also like to echo your thanks to all of our attendees for joining of us today, and also to the three of you for lending your expertise to the field. 

*Merry Ward:*I’d like to add, Molly, you and CIDER have just been incredible.  Thank you, Jonathan and Brenna.

*Moderator:*Thank you.  We do appreciate getting these training opportunities out to the field.  It’s especially nice since funding for meetings is going down.  Anyways, thank you again to everybody for joining us.  Like I said, you are going to receive a follow-up email in a couple of days, which will have a link to this recording, as well as access to the archives slides.  For those of you who printed out the slides before the session, yes, they were updated briefly, so we will have the most up-to-date version that was presented in the archive catalog.  You will be able to access those once we get that up in the online video archive.  I am going to leave this survey up on the screen, so feel free to take your time and answer those questions.  I think that about wraps it up for us today.  Thanks again, everybody.  Have a wonderful day.

*[End of Audio]*

Page 14 of 15