FINDING WISDOM IN THE INFORMA

The VA Clinical Assessment Reporting and The VA Clinical Assessment, Reporting, and 

( CART ) Program Approach

T
Monday, November 30, 2009

51 year old male with history of Hodgkin’s lymphPartially paralyzed diaphragm, reduced lung funcOutpatient diagnosis of bronchitis

Wednesday, December 2, 2009

Outpatient diagnosis of double pneumonia

Friday, December 4, 2009

Admitted to ICU 

Sunday, December 6, 2009Sunday, December 6, 2009

Placed on mechanical ventilationAcute renal failure and respiratory failure
In late 2009, what knowledge knowledge e

e

3
Moving from Information to Wi

X Treat as bron

History

and

X Treat as pneu

Presentation

X Treat as pneu

YES Treat as H1

4
5 Image used wit
Where is the wisdom we have lost in knowle

Where is the wisdom we have lost in knowle

knowle

Where is the knowledge we have lost in infor
INFORMATION

IN THE SERVICE OF

DOCUMENTATION

7
VA Clinical Assessment, Reporting, and Tr

Program

CART

was not di d es gne

d as

a d i ocumentation

tool or

a data registry, but as

a

framework

by which

INFORMATION

could be harnessed to create

KNOWLEDGE

and generate

WISDOM

to

Â make operations more efficient

Â improve quality quality and safetyÂ and provide better and more

targeted care for our Veterans

8
CART Program Mission

To develop develop and implement implement

a single na

na

VA data repository, repository, reporting reporting system

system

quality quality improvement improvement program program program fo

procedures procedures performed performed in VA card

card

catheterization laboratories

.

9
BUILDING A

CLINICAL INFORMATION SYST

10
The Clinical Model

REQUIREMENTÂ Designed by the 

Â Standards

‐based

Â Integrated in CPÂ Faster than dicta

dicta

Â Improves efficieÂ Part of workflow workflow

11
CART Data Standards

NCDR uses ACC/AHA plus NCDR‐developed 

harmonized with oth

like Society for Thora

100%

American College

of Cardiology’s

ACC‐NCDR

y 

ACC worked with the National Coordinator 

gy

National

Cardiovascular

Data Registry

ACC NCDR 4

VA‐Specific

‐ AHA

‐ STS

National Coordinator cardiovascular data st

ACC‐NCDR v4 Additional harmoniza

STS Additional harmoniza

other standards, such 

LOINC, ICD‐10, where 

Submitted to CDISC/H

12
The Technical Model

We were Agile 

Agile wasn’t 

13
Traditional Model

SQL Database

14
The CART Technical Mod

SQL Dtb

METAMODdynamic conof forms th

15

SQL

D

a

t

a

base
The CART Technical Mod

Traditional Object

‐Oriented Programming META MODEL APPRO

Object <type><name

Property <type><

class Provider

string Name

string SSN

Access any property i

a single meta

‐propert

string SSN

class Patient

string Name

Object(‘Patient’).Pro

coded as

getObjectProperty(‘P

string Namestring SSN

Direct coding in

a common object

‐ getObjectProperty( P

• dynamically extens

• we do not need an

Direct coding in

a common object

oriented language will result in hundreds

of objects and thousands of properties and

methods that are all conce

ptuall

y similar. we do not need an

in the meta system 

access new objects 

pro

perties.

p y

3 MAJOR VERSIONS, 20+ Minor Iterations Yearly

(that’s more agile than the iPhone)

16

p p
CART SITES

17
CART Utilization

(as of June 20, 2011)

3,312 Providers

206,601 Patients

231,079 Procedural Procedural Reports

18
THE HEALTH INFORMATICIST’S PR

Oh, Health IT Infrastructure,Grant me the data sources to collect valid,

discrete data,

The knowledge to make some kind of sense o

of all of that data

A dn

d

t

h

e

wi ds

dom to

know

how muc

h caff i e ne 

required in order for me to apply that knowle

to improve care.
CREATING

KNOWLEDGE AT THE POINT OF C
Improving Quality of Care: The Curren

Point

of

Care

Data stored in medical record Data stored in re

YEARS

$$

Patient Safety 

Routine Care

Clinical Rese

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ABSTRACTION OF DATA TO IMPR

QUALITY

IS AFTER THE FACT.

This is necessary because data collection is 

integrated into the process of clinical car

22
TRANSACTIONAL QUALITY AN

MANAGEMENT

“If specific data are needed for patient care, to improve qua

increase patient safety, these data should be available and a

at the point of care and not abstracted after the fact.”

Robert Jesse, VA Principal Deputy Undersecretary for Health
Informatics in the Service of Q

Routine C

POINT OF

CARE

VISTA/ Patient Sa

CPRS

Qualit

Im

provem

CPRS

Clinical Re

p

CART
Informatics in the Service of Qual

Improvement

• Ma

jor Adve

Event Alerts

• Device

Surveillance

• Decision Su

and Beyond

25
The Problems of Device Survei

• Underreporting• Voluntary

= Passive

• Numerators, not denominators

DIFFICULT PR

NOT AT POINT OF CARE

BURDENSOME

TIME

‐CONS

26 http://www.fda.gov/cdrh/postsurv/medsunappendixa.html www.fda.gov/cdrh/postsurv/medsun.pdf

J Gen Intern Med. 2

Arch Intern Med. 
CART-FDA Surveillance

UNEXPECTED PROBLEM with

DEVICE

Entered in CART

Automatic Alert

LEVEL I LEVEL II

Not Specific to the Medical Device

(deidentified – no PHI)

LEVEL II

Potentially Device

( details for novel eve

LEVEL II

Potentially Device

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Patient Complic

(FDA reportable MedW
CART Major Adverse Event Re

Automatic

Notification

Emergent CABG

Stroke

Death

Committee

Review

Recomm

Actio

Resolu

30

da

y

s

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Ok, I have the information

and h d arnessed that to gain

knowledge... But where is

the wisdom?

Use The Force,

you must.
Informatics in the Service of Qual

Improvement

• Reporting a

Benchmark

• L l oca qualit

improveme

• Health Serv

Evaluation

• Targeted

Intervention

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CART Quality: Reports

• Monthly Site QA Reports Reports• National Reports (VACO, CART

‐QM Comm

– Monthly Reports:

• Procedure counts (including fiscal year to date)• M j a

jor

a

dverse event counts (i l di (including fi l sca yea

– Bi

‐Annual Reports

• Detailed Detailed site and ‘roll

‐up’ data; quality quality metrics metrics

• Quarterly VISN

‐level Reports

– VISN CMO’s

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Direct Integration with ACC

-

• Contract, data specifications and map

certification are com

plete

• Based on ACC

‐NCDR v4

• Begin su

b ii m tt ng VA

data

thi

s quarter

32
How do I get CART data?

• The CART Pro

gram is currentl

y under the Office of Patient Care Se

• Re

‐organization will move CART to the new Office of Informatics a

Anal

ytics, and

sp y ecificall

y the Office of Anal

ytics and Business Int

Local Data Local Performance M i Local Data Rese

Metrics Rese

Ex: “I would like tok

h l

Ex: “We would like to

l

Ex: “I want 

know

t

h

e total h li

radiation time per

patient.”

explore our

complication rates for

X, compared to the

national VA average ”

t

h

e quality

Veterans unsaphenous 

national VA average.”

33
How do I get CART data?

LOCAL DATA• Cl if ar

y th

e

type

o

f i f ti n

formation your nee

d ( t no

t an appli ti ca on pro

• Over 40 requests have been made and filled• Some take 45 minutes to complete, others weeksRESEARCH or WORK

‐PREPARATORY TO RESEARCH

• Proposal to the CART Research and Publications Committee (10 

•

Once th

e

t iti ransition is compl t e

t

e

t

o OIA, we

will merge our r

oversight with theirs

• Proposals evaluated based on

• Clinically Clinically important important questions questions, scientific scientific validity validity• Feasibility of answering the question with existing data

• Strategic priorities

Email our National Site Manager, Alec Arney at alec.arney@va.go

34
Patient-Centered Wisdo

Pre‐procedural procedural Procedural Longitu

Care

Procedural

Care

Longitu

and O

Radial, SVG

Interventions;

Radiation exposure

Upstream care and

testing

Me

adh

Decision support Device surveillance Ris

man

P dl roce ural V 

Complications

V

(outco

Informed consent

35
Pre-Procedural Care: Collabor

Pre‐Procedural

Care

Upstream care and

testing

• Appropriateness of cath procedures 

Using Interactive Voice Response (IV

administer the Seattle Angina Questi

Decision support

• Radiation Exposure [Tsai]

Characterize radiation exposure with 

goal of developing decision support t

• Contrast‐induced Nephropathy [Mat

Informed consent

ppy [ 

Automated risk characterization for p

undergoing procedures and prompts 

36
Procedural Care: Collabora

Procedural

Care

• Stent Selection [Brilakis]

Drug

‐eluting vs bare metal stents Radial, SVG Interventions;

Radiation exposure

• Future:

Real Time Locator Services

Radiation exposure

Device surveillance

Bleeding risk assessment

Device surveillance

Procedural

Complications

37
Post-Procedural Care: Collabor

Longitudinal Care

& Outcomes

• Clopidogrel (Plavix) Adherence [Ho]

Improving adherence to Plavix after

placement of drug‐eluting stent, usin

Medication

adherence

automated processes through CART 

interactive voice response follow‐up.

Risk factor

• Blood pressure and lipid control [Ma

Improving control among coronary a

patients in the year following cath.

management

patients in the year following cath.

Value

(outcome / cost)

38
WHAT ELSE?

YOU TELL US.

39
CART Program Expansio

• CART

‐Peripheral

– Thomas.Tsai@va.gov– Lower extremit

y intervention, then carotid 

• CART

‐EP

– Paul Varosy@va gov Paul.Varosy@va.gov– ICD, then pacemakers, then ablation proced

• CART

‐CPR

– Steve.Bradley@va.gov– In

‐hospital cardiac arrest documentation

40
CART-Peripheral: Procedure D
CART-EP: Encounter Informa

42
CART-EP: Device Data

43
Collaborations and Future Dire

Dire

Within VA• OIA/OABI – Web Solutions Group (MDWS)

• Corporate Data Warehouse (CDW)

• Veterans Implant Tracking and Alert System (VITAS)

• Transformational Initiatives

• (T15) H lth ea Care Effi i i c enc es (RTLS)• (T16) Health Informatics Initiative (AViVA)

• Blue ButtonExternal• FDA, NCDR, DELTA, Microsoft

44
THE HEALTH INFORMATICIST’S PR

Oh, Health IT Infrastructure,

Grant me the data sources to collect valid,

discrete data,The knowledge to understand the dataAnd the wisdom to apply that knowledge toimprove care.

45
“What we call the beginn

often the end. And to make a

is to make a beg 

i

The end is where we start f

‐T 

46
Thank You

With special thanks to the entire CART Program staff:

Thank You

John S. Rumsfeld, MD, PhD, Program Director and VA Director of Card

Thomas M. Maddox, MD, MScPaul Varosy, MD

Tom Tsai, MD, MSc

Hans Gethoffer, Dr. Ing

Gary Grunwald, PhD

Meg Plomondon, PhD, MSPH Tami Box

Gregory NoonanAlec Arney, RN, MA

C li O’D ll MS

Tami Box

Tamara.Box@va.gov

Colin O’Donnell, MSBrian GillespieMaggie Stanislawski, MSBlake WoodJosie Nance

Mary McDonell, MS

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