Health Tech Net July 15 2005 Robert M

Health Tech Net July 15, 2005 Robert M. Kolodner, MD Acting Deputy CIO for Health & Acting Chief Health Informatics Officer Veterans Health Administration Department of Veterans Affairs

Vist. A Supports VHA • ~196, 500 Employees – ~15, 000 Physicians – 56, 000 Nurses – 33, 000 Allied Health Professionals PLUS – Affiliations with 107 Academic Health Systems §Additional 25, 000 affiliated Physicians §Almost 80, 000 trainees each year • ~ 1300 Sites-of-Care – Including 157 medical centers, ~ 850 clinics, long-term care, domiciliaries, home-care programs Source: QTR Exec Summary Mar 2005 Health Tech Net July 15, 2005 2

Vist. A’s Cost • VA runs 128 Vist. A systems these sites – Down from 172 Vist. A systems 10 years ago – ~180, 000 PCs and thin clients • For FY 2004: – Cost per enrollee §$78 / enrollee – Average cost per hospital (n=158) §$3. 6 million • Delivers a complete hospital information system, electronic health record, imaging, BCMA – Hardware, software, maintenance, upgrades, staffing Health Tech Net July 15, 2005 3

And Vist. A Is Actively Used. . . Some National Vist. A Statistics (Total / Daily) • Documents (Progress Notes, Discharge Summaries, Reports) – 698, 000……. . +567, 000 each workday • Orders – 1. 4 Billion……. . +931, 000 each workday • Images – 338, 000……… +534, 000 each workday • Vital Sign Measurements – 863, 000……… +676, 000 each workday • Medications Administered with the Bar Code Medication Administration (BCMA) system – 670, 000……… +616, 000 each workday Statistics as of June 2005 Health Tech Net July 15, 2005 4

Medical Computing Status “. . . Given the huge increase in personal computer and Internet use, as well as the dramatic changes in other industries, most consumers assume that healthcare is highly electronic and computerized. The reality, however, is that 90 percent of the business of healthcare remains paper -based. Why? ” . . . Because healthcare (in the U. S. ) is a trillion-dollar cottage industry! ” Rx 2000 Institute http: //www. rx 2000. org/Knowledge. Center/hipaa/elearning/QC_govt. htm Health Tech Net July 15, 2005 5

Except in VA ! Every VA Medical Center has Electronic Health Records ! Health Tech Net July 15, 2005 6

Praise for Vist. A… “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)” Health Tech Net July 15, 2005 7

(Still More) Quotes About Vist. A. . . “…nowhere is the VA outrunning the private healthcare sector by a wider margin than in the adoption of clinical information technology. ” Modern Physician, August 1, 2003 “The Electronic Health Record in the Department of Veterans Affairs is the best in the United States, absolutely the best at large scale, and probably the best in the world. ” John Glaser, Ph. D. , October 2003 Vice President & CIO Partners (Harvard) Health. Care System Health Tech Net July 15, 2005 8

However This is NOT about technology… It is about RESULTS: • Improved Health Care Quality • Improved Health Outcomes Health Tech Net July 15, 2005 9

And in January 2005… Health Tech Net July 15, 2005 10

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 x 3, others x 1) 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 A 1 c checked past year 94 85 83 (NCQA 2002) Diabetes Hgb A 1 c > 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) Health Tech Net July 15, 2005 11

Highest Quality of Care For Patients in VA Measured Broadly “Patients from the VHA received higher-quality care according to a broad measure. Differences were greatest in areas where the VHA has established performance measures and actively monitors performance. ” Annals of Internal Medicine, December 21, 2004 Health Tech Net July 15, 2005 12

Agenda Current Vist. A Healthe. Vet-Vist. A Healthe. People-Vist. A Health Tech Net July 15, 2005 13

Past and Present Health Tech Net July 15, 2005 14

Success In Supporting Health Care Delivery For Millions Of Veterans • Vist. A is a success – Built by “fire” of VHA collaboration – Publicly owned by VA; plan to remain so for the next generation system – Strong interest by public/private in using Vist. A • National software w/ local flexibility/innovation: – Began as a system in each of the 172 major VA facilities – Innovation developed locally & enterprise wide – Standard packages distributed enterprise wide, e. g. latest version of CPRS Health Tech Net July 15, 2005 15

Vist. A Features • Renamed “DHCP” to “Vist. A” w/ the launch of CPRS – Veterans Health Information Systems and Technology Architecture • 100+ separate business packages that support day-to-day activities of healthcare operations, including – Provider systems – Registration/enrollment/eligibility – Management and financial systems Health Tech Net July 15, 2005 16

In 1996, VA launched the “Computerized Patient Record System” -- CPRS-a comprehensive, integrated Electronic Health Record (EHR) Health Tech Net July 15, 2005 17

Vist. A’s Contribution to VA Creating a Culture of Quality: The Remarkable Transformation of the Department of Veterans Affairs Health Care System “What was largely an inpatient, subspecialty-based system became a “full-service, ” integrated delivery system committed to a new model of health promotion, disease prevention, and coordination of care. … The “culture of quality” depended on the successful implementation of several innovations: a uniform data collection system facilitated by nationwide implementation of an electronic medical record system, systematic application of quality standards, and externally monitored local area networks to monitor quality. ” Annals of Internal Medicine, Editorial, August 17, 2004 Health Tech Net July 15, 2005 18

Electronic Health Records & Computerized Provider Order Entry • Computerized Provider Order Entry (CPOE) is one of the Leapfrog Group’s “Top 3 Safety Strategies” §Outside of VA, CPOE < 8% nationally §< 30% among Academic Medical Centers • Nationally, 94% of all VA prescriptions are entered directly by providers §Ultimate Goal: 100% §VA is the Benchmark for CPOE Health Tech Net July 15, 2005 19

Clinical Reminders Contemporary Expression of Practice Guidelines • Time & Context Sensitive • Reduce Negative Variation • Create Standard Data • Acquire health data beyond care delivered in VA Health Tech Net July 15, 2005 20

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Morphing from Vist. A to Healthe. Vet-Vist. A • What has happened in the past year? – Data Standardization progressing in first few domains – Health Data Repository - HDR (version 1) - ready for initial deployment – Launching pilots to implement Regional Data Processing Centers to replace facility-based system distribution – Last CPRS (in Delphi) – Version 26 – due out in October – CPRS-R getting ready for testing – Administrative Data Repository (ADR) concept developed and being pursued – Investing in Common Services and initial Rehosting – Pharmacy re-engineering restructured to deliver in ~2008 – Laboratory re-engineering getting underway this year – Scheduling alpha test delayed until Fall 2005 142 Latest CPRS GUI Enhancements – My Healthe. Vet steadily adding new capabilities Health Tech Net July 15, 2005 25

The Future Next Generation Vist. A……. . Health Tech Net July 15, 2005 26

Vist. A - Why change? • Not lose functionality we have • Strengthen Vist. A – Move to person & data focus – Move to standardized, fully sharable health data §Approximately 30% of veterans receive care at two or more VHA facilities. §An estimated 40% of veterans we treat receive care outside of VHA – Increase system availability and reliability – Increase flexibility to respond to future health needs – Lower cost of maintenance – Modernize & replace older systems – Ensure documentation on application programs – Move to modern technologies Health Tech Net July 15, 2005 27

Operational (Clinical) Drivers for Change • Support our future health system • 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 & maximized function/health (time to zero) – Inconvenience (inconvenience to zero) Health Tech Net July 15, 2005 28

What is Healthe. Vet-Vist. A? • Healthe. Vet-Vist. A – is the REPLACEMENT of the existing Vist. A system by rehosting, enhancing, and/or reengineering current health information applications to process on a new technology platform • Hardware and services – will be redundant (a good thing) and “COOP’ed” [Continuity of Operations] • Modernization effort includes – Systems Platform – Software Design – Development Methodology Health Tech Net July 15, 2005 29

Healthe. Vet Strategy Overview • Built on Vist. A /CPRS foundation – Minimizes change for the health care providers • Built collaboratively – by VHA field/CO leadership & staff and with the Department • Existing components of the current Vist. A system will be retired incrementally – …as Healthe. Vet-Vist. A is deployed in stages – Will eventually replace all Vist. A software §Migratory/evolutionary process as risk mitigation §“Morphing” from Vist. A to Healthe. Vet-Vist. A • Remains publicly owned Health Tech Net July 15, 2005 30

Health Data Repository (HDR) – A Step Towards Healthe. Vet-Vist. A • The “data” layer • A central repository of person-centered clinical & health information – for use by clinicians and other personnel in support of patient-centric care – supports clinical decision-making for better quality, safer patient care, independent of where the patient information was first entered • Health Data Repository (HDR) – Domain-by-domain filling of the national HDR as local Vist. A data is “cleaned” to align with new standards §Start with Allergies, Outpatient Pharmacy, Vital Signs, Laboratory Results by the end of July 2005 §Standardized (and computable) data from all VHA sites VHA will make a “Quantum Leap” as VHA-wide database integration becomes operational Health Tech Net July 15, 2005 31

This is an actual patient who has been seen in 36 different VA medical centers in the past 10 years. Allergy reactants were recorded differently in Cheyenne and St. Louis (and probably in many other sites). For example, Vistaril and Hydroxyzine are the same drug. Decision support will be strengthened when allergy reactants are standardized. Health Tech Net July 15, 2005 32

HDR – The Benefits • Health Data Repository (HDR) – 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) – Fall 2005 - Drug/Allergy and Drug/Drug Interactions across VHA §Increases patient safety across VHA §Will exchange pharmacy & allergy information with Do. D for patients receiving health care in both systems – Provides real-time interaction detection for both VA & Do. D data Health Tech Net July 15, 2005 33

HDR – Some Content • 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 Health Tech Net July 15, 2005 34

HDR – How Is It Different Than Current State? Current State Future State • Facility-centric • Patient-centric (Veterancentric) • Data is not standardized from site to site, therefore it is not computable • Standardization of data becomes the foundation for decision support functionality • Automated Clinical Decision Support uses data only from the local Vist. A system (1 of 128) • Automated Clinical Decision Support is available in real time across all sites of care Health Tech Net July 15, 2005 35

Personal Health Records Health Tech Net July 15, 2005 36

Principles: • The veteran "owns" his/her My Healthe. Vet Personal Health Record My Healthe. Vet (Phase 1) Veterans Day 2003 • The Vist. A Computerized Patient Record System (CPRS) is the authoritative VA medical record • The veteran can request that a copy of his/her Vist. A record be electronically extracted and sent to the My Healthe. Vet system Health Tech Net July 15, 2005 www. myhealth. va. gov 37

My Healthe. Vet is a new ehealth portal where veterans, family, and clinicians may come together to optimize veterans’ health care. What’s Coming…… Three Iterative Implementation Phases: PHASE 1 November 2003 Content Contributors Engagement Showcasing Health Populations Health Tools VA Services Personalization Health Tech Net PHASE 2 November 2004 – Summer 2005 PHASE 3 Fall/Winter 2005 -2006 Electronic Health Record Prescription Refill Self-Entered Information View Appointments View Co-Pay Balance Parallel Tracks Clinician / Patient Messaging Moderated Discussion On-Line Education / Training Self-Entered Metrics July 15, 2005 38

“To be” (VA & Beyond) Health Tech Net July 15, 2005 39

VA, Do. D, IHS individual/joint adoption Consolidated Health Informatics (CHI) Co nv er ge nc e Healthe. People(Fed) National -- Public/Private • Individual (e. g. Kaiser Permanente) • Joint (NHII, Connect. Health, e. HI, HIMSS, NCVHS, SDOs, etc. ) Systems (EHR, PHS/R, Exchange) Health Information Standards Progress Toward US “Virtual Health Systems” National Standards Healthe. People Info Exchange / Sharing Do. D CHCS II & TRICARE Online VA Healthe. Vet/People-Vist. A & My Healthe. Vet High Performance Info Systems IHS (upgraded RPMS) Healthe. People(Fed) National – Public/Private • Individual (health providers/payers/regulators, private sector vendors) • Joint (NHII, CMS/VA, Connect. Health, etc. ) Healthe. People 2001 Health Tech Net US Person. Centered “Virtual Health System” e nc n Co v e rg e Personal Health Systems/ Records 2010 July 15, 2005 40

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 13335 – April 27, 2004 Health Tech Net July 15, 2005 41

Vist. A Is Being Enhanced For Use By Non-VA Providers • VA is partnering with Centers for Medicare and Medicaid Services (CMS) to ensure availability of high quality, standardized, interoperable and affordable electronic – Hope to stimulate broader adoption & effective use of EHRs • Vist. A - Office EHR – A version of Vist. A configured to be affordable and to meet the needs for use in community health clinics and office based practices in rural and underserved areas – Goal to make an EHR available to 1 -8 physician practice – Doctors Office Quality Information Technology (DOQ-IT) connectivity to Vist. A Office EHR – Enhancements will be incorporated into core Vist. A & will reflect changes made in core Vist. A – only 1 version of Vist. A – Expected release – August 2005 – More information at http: //www. cms. hhs. gov/quality/pfqi. asp Health Tech Net July 15, 2005 42

Current Vist. A Is Already Used Elsewhere • Currently used by several non-VA organizations (partial list) – Indian Health Service (modified version of Vist. A) – Egyptian National Cancer Institute – American Samoa – DC Department of Health – Oklahoma State Dept. of Veterans Affairs (State Veterans Homes) • Other healthcare organizations are exploring the use of Vist. A Health Tech Net July 15, 2005 43