1. Big Data and VistA Evolution
Presentation to Open Source Electronic Health Record Alliance (OSEHRA) Architecture Work Group
Theresa A. Cullen, MD, MS
Chief Medical Information Officer
Director, Health Informatics
Office of Informatics and Analytics
Veterans Health Administration
Department of Veterans Affairs

2. Agenda Overview of the Department of Veterans Affairs (VA) Big Data
VistA Evolution

3. . . . . . Patient and Provider Patient Population
Patient, Provider, and Patient Family
Population
Patient
Community . .
. . .

4. Overview of VA

5. Hospital System to Health System
In 1996, VA began the creation of Veterans Integrated Service Networks (VISNs) to transform VA Health Care from a “Hospital System” to a “Health System.”
Veterans Health Administration (VHA) currently has 21 VISNs.
152 Medical Centers
990 Outpatient Clinics Community-Based Hospital-Based Mobile Independent
300 Vet Centers
ID:15
Created for VHA Overview Version 1.6/13/2011
Updated 1/22/2013 to reflect FY th Quarter pocket card:
70 Mobile Vet Centers
102 Domiciliary Residential Rehabilitation Programs
134 Community Living Centers
Source: FY 2012 End-of-Year Pocket Card

6. VA’s Health Care Delivery Model
Personalized, Proactive and Patient-Driven
Team Care
Continuous Improvement
Data-Driven, Evidence-Based
Value
Prevention / Population Health
ID:23
Created for VHA Overview Version 2.7/18/2011
Edited 1/10/2013
 Coordinated Care

7. Big Data

8. Collect and Blend the Big Data
CUT
MIX
DICE
BLEND
Japan and connectedness.. Finish with story and a quote and the Blender picture
Comment about letting people in on the freeway
PARSE

9. Secondary Data Use: Research and Predictive Analytics Capabilities
Providers can’t accurately predict Veterans at highest risk of deterioration
Patient Aligned Care Team Registered Nurse (RN) Care Managers charged to coordinate care
No systematic way to identify Veterans who might benefit most  predictive analytics using data from Electronic Health Record (EHR)
Home-based primary care
Case-management
Specialty clinics, e.g., heart failure
Telehealth
Palliative care
Broad range of clinical programs designed to improve care for Veterans with complex chronic illness
VHA provides a broad range of programs for patients with chronic illness to improve outcomes and prevent hospitalizations:
Home-based primary care
Case-management
Specialty clinics, e.g., heart failure
Telehealth
Palliative care
However, no systematic way of targeting programs or identifying patients who might benefit most
Knowledge of a patient’s risk of adverse events could help to target delivery of intensive services to those with the potential to derive the most benefit
Doctors and nurses cannot accurately predict who is at highest risk of deteriorating or dying
Predictive analytics using data from many sources including EHR could help to identify highest risk patients and target services.

10. What’s Wrong: Data-Domain Centric
Building blocks of EHR are data domains
Meds, Labs, Rad, Notes, Diagnoses, etc.
Results in bad thought-flow and workflow

11. Moving From What’s Wrong
Data Silos
Data Juxtaposition
Data + Workflow Integration

12. Implications of Conceptual Approach
Goal - construct user-interface components to facilitate clinical reasoning and work
Address basic cognitive needs – then reuse or reconfigure for most health care processes
Avoid “an app for that,” while allowing for extensibility

13. Standard Orders

14. Developing Context-Sensitive Orders
30 million records – 20 years of data mined to identify relationships between
Problems
Laboratory results
Prescriptions
Procedures
Orders
Location
Provider
Patient
15,000 conditions and 10,000 orders

15. Common Test and Drug Orders
Epigastric pain
CBC with diff
Chemistry panel
Helicobacter pylori
Lipase
Amylase
Upper GI endoscopy
Abdominal ultrasound
CT abdomen w/o contrast
Omeprazole
Ranitidine
Amphogel
Rabeprazole
Promethazine
Sucralfate
Metronidazole
Metoclopramide
Docusate

16. Characteristics of VHA Analytic Approach
Treat corporate data as strategic resource, available to entire organization
Maximize understanding of organizational processes and outcomes to promote learning and improvement
Invest in relevant, role-based training in analytics so tools are available widely and not just to a few

17. Products For clinicians Real-time, structured data collection
Population and panel management tools
For leadership
Understanding organizational performance and vulnerabilities
For public/consumers
Unparalleled transparency and public reporting

18. Care Assessment Need (CAN) Report
CAN provides estimated probability of death/hospital admission w/in specified time frame (90d or 1 yr)
Score expressed as a percentile 0-99; higher score indicate follow-up assessment
Provides patient level detail
Accessible through VHA Support Service Center (VSSC) website and Computerized Patient Record (CPRS) tools menu
For primary care providers, and/or nurse care manager
Model developed in collaboration with VA researchers and policy leaders

19. VHA’s Analytic Journey – Summary Themes
Leverage and integrate information (break down silos) to gain insight and efficiency
Collaborate across multiple data sources and agencies (e.g., Veterans Benefits Administration, Department of Housing and Urban Development (HUD), Department of Health and Human Services (HHS))
Move from retrospective performance reports to real-time prediction, decision support, and practice support
Enhance analytic skills throughout Veterans Health Administration (VHA) workforce
Promote transparency and accountability

20. VistA Evolution

21. Background
In 2013, VA and Department of Defense (DoD) Secretaries made decisions that require a change in EHR strategy
The VA EHR core will be VistA-based
Our mission has not changed
“to care for him who shall have borne the battle, and for his widow, and his orphan”

22. Current VA Landscape
VLER Health
Connected Health
Over the past several years, various products have been developed across the VA landscape, creating a complex suite of applications
Janus JLV
VistA Web
VistA
CPRS
iEHR
RDVs
CAPRI
VistA Standardization
HMP
Acronyms:
CAPRI – Compensation and Pension Record Interchange
HMP – Health Management Platform
iEHR – integrated Electronic Health Record
JLV – Joint Legacy Viewer
RDV – Remote Data Views
‘Conceptual’ representation of current
EHR/Health Information Technology Landscape

23. 2014 2015 2016 2017 Roadmap Full Operating Capability (FOC)
Initial Operating Capability (IOC)
Office of the National Coordinator (ONC) Certification 2014 Criteria
Interoperability
Full Operating Capability (FOC)
2014
2015
2016
2017

24. VistA Evolution Management Approach
Continuous feedback and improvement
Engaged customers and stakeholders
Just in time requirements
An agile-UX-Value Management approach allows high-level, very broad modeling and planning at the beginning of the project to address the majority usability, UI, and project risks facing the team. 
Value Management
Feature Driven Design
Agile Principles
Focuses on system behavior and usability
Requires some system modeling and design upfront
Plan the program before starting work

25. VistA Evolution Program Goals
The VistA Evolution Program will support this strategic plan through continual investment and delivery of scalable and modular EHR and Health Information Technology (IT) products to improve the quality, safety, efficiency, and satisfaction in health care for Veterans through:
Interoperability
Implementation of an open and extensible EHR system
Establishment of interoperability between VA and DoD EHR systems
Re-engineering of business processes in collaboration with users of health IT

26. VLER and IPO define the interoperability standard
VistA
Federal Partners (DOD, IHS)
By end of 2017, we will have an architecture and framework that supports interoperability, care coordination, meaningful use and partnership and which has been certified to the Office of National Coordinator (ONC) 2017 Edition certification criteria to support meaningful use demonstration by VA providers and hospitals
Integrated Architecture
and Services
User Experience
VBA
Care Coordination Framework
VLER and IPO define the interoperability standard
Vision
A user experience that integrates information for improved quality and effective clinical decision taking
Multi-provider information sharing tailored to the patient's clinical condition, care goals, and physician best practices
Provides the capability for clinicians and researchers to define and manage patient population data.  A patient population is a cohort formed by applying specific criteria (e.g., age, weight, disease, allergies, location).   "Rural Diabetic Veteran ages 55-65 exhibiting macular degeneration" would be a type of patient population
Management of activities that improve human and material resource utilization and clarify plans of care
Explicit incorporation of patient goals in the care plan, to support patient-defined terms of success
Enterprise-wide deployment
Standard Data Model
Open Source/
Community Partners
Acronyms:
DoD – Department of Defense
IHS – Indian Health Service
VBA – Veterans Benefits Administration

27. Three Key Interoperability Concepts
Technical (syntactic) Interoperability
Allows computers to reliably exchange data, so it can be read at least by humans.
Accomplished with messaging protocols and data formats.
Semantic Interoperability
Allows computers to unambiguously and consistently determine meaning of the data for presentation and decision support.
Accomplished with standardized terminologies like ICD10 and SNOMed.
Process Interoperability
Allows computers to exchange and track workflows as patients or orders move between organizations; includes care plans.
Accomplished with standardized business process notation or workflow protocols.
Ex. 1: sending prescription requests from VistA to community pharmacies;
Ex. 2: tracking care plans for follow-up on cancer suspicion from X-ray
Ex. 3: continuing polytrauma care plans as patients move between VA and DoD.

28. How Do We Get to Seamless Interoperability ?
Principles
Mapping to National Standards is the correct approach
VA investment will improve interoperability with DoD and other health care partners
“First No Harm”
VA must balance permitted uses of shared data with our level of confidence in coding and content accuracy
The possibility and degree of harm
 100% mediation is NOT to be expected
Mediation rates in Clinical/Health Data Repository (CHDR) are ~80%
This is still an improvement over “No Data”

29. How Do We Get to Seamless Interoperability ?
Interagency Program Office (IPO)
Provide and maintain complete, accurate, and meaningfully interoperable data from all domains required to achieve clinical objectives and meet regulatory requirements (semantic interoperability)
VistA Evolution
Improve technical infrastructure for health data interoperability while reducing overall system complexity (improved syntactic interoperability)
Convert to standards-based services, formats, protocols, and data models
Enable expanded and improved data exchange with partner providers

30. VistA Evolution Program Objectives
Provide program structure, management ,and governance to oversee requirements management, acquisition, risk management, communications, training, and transition planning.
2. Establish and maintain flexible system and enterprise architectures that support interoperability with internal and external partners, and support new applications and features that meet clinical needs.
3. Establish and maintain methods to develop business (clinical and administrative) processes and to revise existing procedures and policies that advance VA health care and health informatics capabilities.

31. VistA Evolution Program Principles
This VistA Evolution Program Plan is based on the following principles to ensure the highest standards of program execution:
Focus on our Servicemembers, Veterans, and their family members.
Enable health care that applies the appropriate and most efficient resource to the task of providing the highest quality care while maintaining a focus on prudent custodianship of tax payer resources.
A cohesive, forward-looking architecture which maintains affordability while enabling a steady and reliable evolution forward, incorporating state-of-the-art technology while leveraging the knowledge base and processes that create a patient-centric health care environment.

32. VistA Evolution Program Management
The importance, size, and complexity of VistA Evolution requires adoption of robust constructs for organization and governance structure.
The organization of scope, schedule, and cost must include the business, technical, and program functions.
The organizing framework must be detailed enough to practice Value Management yet ‘light’ enough to enable agile management and development when appropriate.
The work breakdown structure must align to iEHR capabilities and to business functions
Consensus is needed on artifacts and frameworks used to execute the program.

33. VistA Evolution Program Plan Purpose
The Program Plan defines the Who and How of the VistA Evolution Program
Management Approach
Governance for Program Planning, Change Control, and Risk Management
VistA Evolution Product Approach
EHR Certification and Meaningful Use
Requirements Management Strategy
Communications Strategy
Training Strategy
Transition Strategy
Work Breakdown Structure

34. VistA Evolution: The Product
The VistA Evolution product provides the infrastructure and open, extensible platform on which tools and services can be integrated in support of Veterans’ evolving needs, in pace with the technological landscape. The VistA Evolution Product will be incrementally developed and deployed through Fiscal Year (FY) 2017.
The VistA Evolution Product will:
Deliver on the VA and DoD Secretaries’commitments to accelerate full health data interoperability between VA and DoD
Tie together disparate threads of clinical data into one care coordination plan available to the entire clinical care team
Deliver the greatest quality of care that supports the health status goals of Servicemembers, Veterans, and family members
Will be incrementally delivered through FY17

35. VistA Evolution Product Vision
The 4-year product vision for the VistA Evolution Product includes:
A user experience that integrates information for improved quality of clinician and patient reasoning;
Sharable Clinical Decision Support (CDS) to promote best clinical practices tailored to the patient's clinical condition and health-related goals;
Capabilities for clinicians, managers, and researchers to define and manage patient populations;
Management of activities that improve human and material resource utilization and clarify plans of care for all members of the team including the patient;
Explicit incorporation of patient goals in the care plan, to support patient-defined terms of success, and;
Enterprise-wide deployment.
Achieve ONC 2014 Edition certification by September 30, 2015.
Achieve ONC 2017 Edition certification by September 30, 2017.
This pathway supports the triple goals of improving the experience of care, improving the health of populations, and reducing per capita costs of health care.

36. Product Management: Feature Driven Design Process
Identify Vision
Identify Projects and Teams
Create Models
Envision
Determine user needs from real, actual users
Develop user personas and scenarios
Investigate pain points in current system
Investigate options for meeting user needs
Investigate process tooling
Speculate
Organize user needs into Features and Feature Groups
Develop multiple designs for Features
Design and test Throw Away prototypes with real users
Create lightweight Real prototypes of the best designs
Adds/Cuts on selected designs
Create lightweight specs for development
Explore
Write code and implement specs
Test features for code quality
Test features against scenarios with real users
Integrate with other Feature Groups and System
Adapt
Deliver product
Pass along key learning's
Celebrate
Close
Allows for substantial upfront design and iteration and evolution in development
This is needed to deliver features requiring highly refined design for User Interface (UI)/User Experience (UX) controls, layout, and interaction

37. VistA Standardization
VistA Evolution
VistA Evolution
Product
VistA legacy
Connected Health
VLER Health
CPRS
CAPRI
VistA Web
RDVs
HMP
Janus JLV
VistA Standardization
DoD
iEHR
Beginning with delivery of new features by September 2014, we will analyze and begin to synthesize existing features into a new platform
A single viewer will become the starting point for a new user experience to support Patient Aligned Care Teams, patients, and the population
Acronyms:
HMP – Health Management Platform
JLV – Joint Legacy Viewer
RDV – Remote Data Views

38. VistA Evolution Initial Operating Capabilities (IOC): September 2014
Capabilities enabled at two sites: Hampton Roads and San Antonio
Advanced User Interface Tools (via Health Management Platform)
‘Google-like’ Search across database
HL7 Context-aware ‘InfoButtons’ integrated into User Interface
Medication review tool
VA/DoD Information Sharing (via Joint Legacy Viewer)
Immunizations
Modernize VistA immunization files, incorporate required ‘CVX’ format
Facilitates enabling of read/write/exchange + advanced CDS in FY15
Enables new sources of adoption: VA Innovations, OpenCDS, IHS RPMS
Laboratory Information System Acquisition
Modernization and automation of ‘back-end’ lab processes
Facilitates data exchange , business process interoperability, and enhanced CDS
VistA Standardization
Certification of 74 standardized VistA application routines in production (complete)

39. ONC 2014 Edition Certification of VistA
ONC 2014 Edition Certification Criteria
VA intends to certify 46 criteria by September 30, 2015
The following criteria will not be certified:
(f)(5) Cancer Case Information (optional)
(f)(6) Transmission to Cancer Registries (optional)
(g)(1) Automated Numerator Recording (VA will certify (g)(2) Automated Measure Calculation instead)

40. VistA Evolution Full Operating Capability (FOC): September 30, 2017
Phase Two of the VistA Evolution is referred to as FOC and will be implemented from the end of IOC (September 30th, 2014) and completed by September 30th, 2017.
The functional focus areas for FOC will:
Propagate the usability features and end-user experience throughout all VistA Evolution to improve user adoption, productivity, and satisfaction;
Continue the adoption and implementation of interoperability standards for sharing clinical records across organizations;
Enable patient-centered care coordination as the care model woven throughout the design, and;
Finalize the enterprise deployment of state-of-the-art laboratory and pharmacy ancillary systems, while leveraging process re-engineering to ensure best practice operations for efficiencies, quality of care, and patient safety.
The resulting VistA Evolution FOC application suite and underlying technical architecture will represent a state-of-the-art enterprise EHR solution that has been certified to the forthcoming ONC 2017 Edition certification criteria.

41. Keeping the Patient in Focus

42. Questions?
Contact Information:
Theresa Cullen, M.D, M.S.