The VA Cardiovascul

Assessment, Reporting, 

Tracking System for Cath 

John S. Rumsfeld, MD PhD

Clinical Director, CART-CL

Staff Cardiologist, Denver VAMC
Broad Backgroun

Broad Backgroun

z Congressional mandate: VA to provid

least equivalent’ to non-VA sector

– Explicit comparison required

z Problem: No direct VA and non-VA 

available on representative scale

– Internal quality improvement programs– Electronic medical record, but significan

in narrative text

– Administrative and pharmacy databases

z Concern: Veterans have more comorb

worse health status, lower SES than n

Grover FL et al. Ann Thorac Surg 199Rogers WH et al. J Ambl Care Manag
On a positive note On a positive note

z Previous comparative studies sup

equivalent VA cardiac care

– No difference in post-MI mortality– VA patients at least as likely as Fee-For

patients to receive guideline indicated mfor MI

Petersen LA et Peterson LA eFihn SD NEJM 

Acute MI
The Harvard Rep

The Harvard Rep

z Comparison of matched VA and Med

patients 1997-1999 (n=13,129 in each 

z Main Results:

– VA patients traveled further to hospital – VA patients much less likely to be admi

with onsite cardiac cath facilities

– One year mortality: VA 34.5% versus M– 30-day revascularization: VA 22.0% vs. 

44.9%

z Limitations: Veterans more comorbid

estimated SES, administrative data, mclinical data

Landrum et al. Hea

Heidenreich PA, Hea
As if that weren As if that weren

’t eno

t eno

z New England Journal of Medicin

– 1,665 VA patients; 19,305 Medica– VA patients less likely to undergo 

when indicated by guidelines at tim

z 44% versus 51%z Odds Ratio for cath (VA vs Medicar

CI 0.57-0.96)

– ‘There is underuse of needed angio

AMI in both the VA and Medicare the rate of underuse is significantly the VA’

Petersen LA 
VA Response VA Response

z Cardiac Care Initiative

– Regional cardiac care plans (hub/s

and local ACS care pathways

– New cath labs– National VA performance measure– Chart review of all AMI and unsta

patients 

– Focus on cardiac procedures – H

In whom? Results? Safety?
Black Hole Black Hole

z Number of cath labs in VA

– 70, 72, 75 ?

z Number of cath labs in VA using diff

reporting / database systems

– 70, 72, 75 ?

z VA administrative data compared to 

cath lab logs

– Average discrepancy 40%

z No QI program for cardiac care/proce
Create a national VA cath l

repository, including software fo

and report generation for all VA 

as part of a national QI pro

The CART The CART

-CL Pro

CL Pro

Cardiovascular Assessment Reporting and Tracking Sy

Cardiovascular Assessment Reporting and Tracking Sy
Who?

z Other key collaborators / communications: 

Directors/CMO’s/ISO’s, Clinical ProcedurACC, Individual Facilities (administration, technical, ISO), PBM, CICSP, ViSTA Ima

IHD-QUERI

PCS O
Institute of Medic

A New Health

Effective Safe Timely 

Equitable

PatientCentered

Highest Quality Health C

What?
3⁄4 Software must be clinically usefu

• No duplicate data entry• Used as part of regular clinical care

 Pre-Procedure, Diagnostic Procedure, 

generation for CPRS, while automaticaldata

 No new personnel

• Flexible graphical user interface com

categorical data entry and ‘free’ text

• Core of American College of Cardio

elements/standards

Project Requireme

Project Requireme
3⁄4 Integrated with CPRS

• Launch within CPRS; Flow of data to an

3⁄4 Easy to modify/update/expand

• New/evolving clinical, administrative, re

3⁄4 Centralized national data reposit

• Not ‘75 databases for 75 cath labs’• National workload capture for VA (link 

DSS/PCE/billing)

• Support local QA for sites (access to the• National QI program – feedback to sites 

benchmarking, both within VA and VA 

More Requiremen

Requiremen

Timeline Timeline

3⁄4 June 2003: ‘Seed’ funding from 

Services

3⁄4 August 2003-present: Software d

• Small group of clinicians (3) work

with small group of technical folks (programmer, database architect)

3⁄4 Feb 2004: Prototype demo to VA 

Leadership Board

3⁄4 May 2004: Project funding3⁄4 June 2004: Software deploymen

VAMC
Timeline, Timeline, con’t

3⁄4July-Dec, 2004: ‘Beta testing3⁄4Jan, 2005: Data repository ‘li3⁄4Jan, 2005-present: Increment

installation with ongoing clintesting / feedback / modificatexpansion

3⁄4As of today, all 75 sites insta

process
More Technical (slig

More Technical (slig

z Model-driven application

– Extensible database– Extensible application– Over 95% of application is not dir

z Data repository = Microsoft SQL z Software developed in Delphiz Integration with CPRS via RPC’






http://vhaechcartweb/
Implementation Pro

Implementation Pro

1) Clinical site contact(s)

• Cath lab director

2) Technical contact via clinical c3) Web demo if requested 4) CART-CL technical team wor

technical folks to set up (instal

• Remote permissions• Remote set up / modest work fo

5) Once set up, in-service with cl

champion

• Remote, 1.5 hour in-service• Local champion teaches others a
Implementation Conc

Implementation Conc

Model: Macro and M

Model: Macro and M

Adapted from Kitson, Harvey, and McCor

Evidence

Context

Facilitation

Im

VA 
Clinical Acceptan

Clinical Acceptan

3⁄4 As of 4/15/07:

• Use by 837 VA clinicians• >48,000 reports generated on >27,000 p

3⁄4 Implementation process has wor

• Rapid clinical adoption at most sites

3⁄4 Positive clinician feedback

• Ease of use• Time-saving over previous methods• Integration with CPRS / format of notes• Commitment to contribute to a single na

repository and QI program (including pparticipation in ACC-NCDR)

• Local QA, Workload capture, JCAHO h
“With CART-CL- the fellow and attending 

and CART-CL, and enter angio and hemotogether as a "team" generating the cath IMMEDIATELY after the case, which as yappears directly in CPRS as a completed fellows and attendings are very pleased bimmense time saving- only one report is nadministrative headache of tracking is ne

Sample Email Comm

Sample Email Comm

from Ed from Ed Toggart Toggart, MD, Cath Lab 

, MD, Cath Lab 

West LA VAMC West LA VAMC
Improve Clinical C

Improve Clinical C

3⁄4 Documentation

9 Data entry based on ACC standards9 Reinforces information already in CPR9 Improves review of data within cardiol9 Carry forward of data in CART-CL to 

3⁄4 Communication / Continuity of 

9 Cardiology procedure results now part 9 Standardized reports improve commun

between VA centers
Quality Improvem

Quality Improvem

3⁄4 National data now available to e

care we provide

3⁄4 Sites have access to their own d

QI

3⁄4 VA participation in ACC-NCDR • Participation in ACC-NCDR qualit

programs9 Obviates need for full VA-only 

3⁄4 National VA Cath Lab ‘Commu
Patient Safety Patient Safety

3⁄4 In lab complications3⁄4 Follow-up module3⁄4 Link to other VA data sources t

longer-term patient outcomes• Example: stent thrombosis follow

3⁄4 Unexpected problems with dev

• Working with FDA

o CART-CL as national patient safe
Research Research

3⁄4 Clinical and health services rese

to cardiac procedures• CART-CL data in and of itself• Link CART-CL data to other VA data 

9 Mortality, hospitalization, pharmac

• Use CART-CL within broader clinical 

3⁄4 Quality Improvement Research

• Care delivery interventions• Assess impact of QI, policy, clinical ca
Administration Administration

3⁄4 Program Evaluation

• Workload capture of cardiac proc

into the CART application

• Link to billing, administrative da• Inform planning for future cardia

(procedure capacity, cost, etc.)

• Quality oversight (Dr. Jesse)
Platform for Expan

Platform for Expan

3⁄4 CART-ACS3⁄4 CART-Peripheral3⁄4 CART-ICD3⁄4 CART-CPR3⁄4 Other diseases / procedu
Variation in Implemen

Variation in Implemen

z Project Delays

– ‘Scope creep’ (e.g. workload capture, J– VA data security crisis– Technical challenges (e.g. C&A, labs, 

z Site-specific delays

– Technical (e.g. remote permissions)– Clinical (e.g. alternative local solution)

z Formal study of variation in CA

implementation, including identkey facilitators and barriers (QU
Attributes of

Clinical Task

(cath reports, data

repository, QI, etc.)

Attributes of

Users

(clinicians)

Attributes o

Technology

(CART-CL applicat

ADOPTION

System

fit fit

fit

facilitators/barriers facilitators/barriers

facilitators/barriers

Health IT Adoptio

Health IT Adoptio

Adapted from: Ammenwerth et al. BMC Medical Informatics and Dec
Sample Barriers Sample Barriers

z Lack of clear local clinical chamz Competing local solutionsz Clinical inertia / noise to signalz Failure to engage local IRMSz Unexpected security and technic

(national and site-specific)

z Challenge of ‘production versio

while still ‘testing/modifying’
Sample Facilitato

Sample Facilitato

z National administrative backing

– Email from Dr. Jesse to Chiefs of Cardio

Dr. Kolodner to IRMS, National Directi

z Engagement of local clinical champioz ‘One site at a time’ engagement, testi

participation

z Flexible software application (ease of 

saving)

z Integration with CPRSz Desire to contribute to national data r

+ ACC-NCDR
3⁄4 Value of clinician-driven

software development

• Software as a ‘clinical tool’

3⁄4 Core of data standards3⁄4 Extensible database architecture3⁄4 Stay ‘within’ CPRS3⁄4 Don’t wait on possible national tech

‘solutions’ / changes (but talk with e

3⁄4 Small, effective project group

• Importance of Hans Gethoffer

Other Lessons Lear

Other Lessons Lear

Technical Technical
• Importance of ‘clinical champion

overstated

• Yet...the backbone of success is t• Integration into broader system o

efforts

• Engagement of administration / fi

administrative goals

Final Lessons Lea

Final Lessons Lea
Administrative support

Clinician leaders

System ch

information tec

protoco

collaborativ

Benchmarking

Quality Improveme

Data

Iterative Evaluation
CART-CL Progra

CL Progra

3⁄4 Leadership / Oversight

• Steve Fihn (IHD-QUERI)• Bob Jesse/Mahdu Aggarwal/Mike Kussm

Services)

• Hank Rappaport/Rob Kolodner (Office o• Jon Perlin (Former Acting Undersecretar

3⁄4 CART Project Team

• Clinical Director (JR)• Technical Director (Hans Gethoffer)• Technical/Analytic Team (Brian Gillespi

Tami Box, Meg Plomondon)

• Administrative Coordinators (M. McDon
Thank You Thank You

John.Rumsfeld@va.go