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Reading for Fun – Official History VistA*/U.S. Department of Veterans Affairs national- scale HIS Steven H. Brown, Michael J. Lincoln, Peter J. Groen,

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Presentation on theme: "Reading for Fun – Official History VistA*/U.S. Department of Veterans Affairs national- scale HIS Steven H. Brown, Michael J. Lincoln, Peter J. Groen,"— Presentation transcript:

1 Reading for Fun – Official History VistA*/U.S. Department of Veterans Affairs national- scale HIS Steven H. Brown, Michael J. Lincoln, Peter J. Groen, Robert M. Kolodner International Journal of Medical Informatics 69 (2003) 135/156 VistA Document Library (VDL)

2 (With Pharmacy Additions) Richard Pham, PharmD Enterprise Architect OI&T Corporate Data Warehouse – Architecture

3 The Health Care System Is MUCH MORE COMPLICATED Than Other Business Processes (~7% of VistA)


5 Each Process Is A World Unto Itself

6 DHCP/VistA/CPRS VistA – Veterans Health Information Systems and Technology Architecture - Refers both to the architecture and the database which the architecture supports DHCP - Decentralized Hospital Computer Program – The DOS (Unix-like) system where many of VistA’s non-clinical entries take place CPRS - Computerized Provider Record System – A user- friendly GUI providing access to clinical order entry functions

7 Objectives The main objective is to understand the data lifecycle of VA’s VistA/CPRS and the user experience of VistA/CPRS A high-level overview of VistA Internals Learn about data structures and outputs in VistA Learn where data enters and travels throughout the VA Try to make sense of data resources within the VA and how they are accessed

8 The VA Data Lifecycle


10 Core Patient Care Functionality VistA is first and foremost an Electronic Medical Record. The architecture design supports veteran health care.

11 Core Patient Care Functionality VistA Internals DHCP CPRS

12 VistA Internals 101 MUMPS Server and Operating System Kernel “Three Wise Men (Managers)” TaskMan MailMan FileMan Modules

13 Massachusetts General Hospital Utility Multi-Programming System (MUMPS or M) My definition in English: M is a programming language designed for hierarchical databases that is convenient for medical applications or anything else where speed and data storage upkeep are a problem and programmer intelligence/organization is not My technical definition: M is a Turing-complete, low and high-level, imperative, machine-compiled (no longer interpreted) programming language utilizing a hierarchical global array file structure Used commonly in healthcare and financial industry settings

14 Structure of The Veterans Administration Data Efforts (Late 1970s) VHA Ancestor Department of Medicine and Surgery (DMAS) VHA-OI Ancestor Computer Assisted System Staff (CASS) OI&T Ancestor Office of Data Management & Telecommunications (ODM&T)

15 Comparing The Two Offices CASS ODM&T Decentralized design philosophy Rapid, agile development SME-involved development Centralized design philosophy Bureaucratic, process-focused development Development without SME’s

16 Highlights of ODM&T Development Took 6 years to deploy APPLES Pharmacy at 10 sites A 1980 paper detailing ODM&T’s transactional patient treatment file (PTF) system promised an interactive national solution by 1990. Navigating the mandated 17 steps between system specification and deployment alone is said to have required at least 3 years.

17 Beginnings of DHCP There were subject matter experts that believed that they could put out useful applications faster than the ODM&T sloth Development of the testing and principles was done unofficially throughout the late 1970s The Second

18 Original DHCP Design Principles A commitment to rapid prototype development All use ANSI MUMPS Modular Design Actively Maintained Data Dictionary Code Sharing/Portability Involve the SME’s

19 DHCP Kernel Functions as both an operating system for VistA applications and an M virtual machine Kernel shields DHCP modules from needing to know hardware and OS configurations on the server Isolates M to the ANSI standard (1995) Provides a toolbox of standard functions for most programmers

20 VistA to Relational Database Terminology VistA (Example)Relational Database (Example) Namespace (VHAFRE)Database (VA Fresno) “Package” – Not hardcodedSchema (RxOutpatient) File (50.68 – VA PRODUCT)Table (NationalDrug) Field (.01 – NAME)Column (DrugNameWithDose) Domain (cardinal/decimal, setofcodes, freetext/wordprocessing) Field Type (numeric, boolean, varchar) Internal Entry Number (IEN or.001)~Key (9722) RecordTuple/Row (ISOSORBIDE MONONITRATE 120MG TAB,SA)

21 MUMPS Classic Database One Data Type String (Text) Other types Cardinal Numbers Float Numbers $H Dates One Data Storage Type Multidimensional Array aka Globals Dynamic (duck) typing

22 VistA Data Organization Namespace File Field Record 654 (VAMC Reno) File 120.5 (GMR Vitals) Field 0.1 (DATE/TIME VITALS TAKEN) IEN-1, BP, 140/90 Most Files have an entry at the 0.001 Field called “IEN” or “Internal Entry Number” as an identity key to mark the record as unique

23 Upside of Using Globals Faster - No joins Faster – All parameter pointers built in Faster – Direct and planned programmatic access to database (Look at SQL execution plans) Less Data Storage Overhead and faster paging – If the data point does not exist in the array, there does not need to be a fixed point like in relational

24 Downside of Using Globals No Intrinsic Structure and No Enforcement* - M believes whatever you put into the globals (most M programmers view this as an advantage while relational programmers have an MI) ACID-compliance not mandated (Il)logical data structures guaranteed – There are many interesting* ways that the M programmers modeled the data that does not make sense to later viewers

25 MUMPS Quirks Whitespace (Space) matters Requires knowledge of kernel and sometimes lower- level concepts Programming Without Type or Structure Enforcement VA programming standards and conventions


27 The Three Wise Men (Managers) TaskMan – The man(anger) that schedules tasks to the kernel MailMan – The man(anger) that messages between the user, TaskMan, and any other two-way communication between packages FileMan – The man(anager) that controls internal file (data structure) interactions

28 TaskMan TaskMan handles application processing: Creation of application processing tasks Scheduling these tasks Monitoring health/statistics of these tasks If kernel is the brain, then TaskMan is the body of the operation If programming, NEVER EVER use the TaskMan global. This subverts TaskMan’s scheduling queue, and can cause a system memory leak. Use the calls instead…

29 MailMan VistA needs a way to pass and receive data from the database to other areas MailMan fulfills this function in the pre-TCP/IP days “Electronic mail” doesn’t mean just email Practically any message between the database and anyone else (the end-user, another site, or application, etc.) can be moved this way Gives programmers methods to both receive and return data to the database

30 FileMan A higher-level method to access the VistA database without exposing a programmer interface Mostly menu-driven One can use limited programming Serves as the model for all other modules that interact with the VistA database

31 ODM&T Initial Action Plan To DHCP Development (1980) Ordered that development stop Fired the developers Removed the hardware Cut the DMAS budget so it would never happen again…

32 The official history

33 Development Goes Underground Developers that survived the ODM&T purge continued their work as a black project in DMAS During 1980 and 1981, the survivors (Underground Railroad) continued work on developing modules for system integration

34 Modules Modules are programmed to interact with the VistA database Most use Fileman as a model for programming

35 Some of the Many Modules MedicineSurgeryDentistryNursingPharmacy LaboratoryCare Management Patient Care Encounters ADTMental Health EDISOncologyNutrition and Food Service Imaging/PACSProsthetics Not really in the scope of this presentation to cover each module. Try the VistA Documentation Library: Or VHA eHealth University (VeHU):

36 Acceptance and DHCP 1.0 Once there was a critical mass of packages that were shown to be useful, the tide turned and the project was blessed… Initial testing done in 1980-83 1.0 installation was in 1985 Most of the underlying packages can still be recognized by the original programmers

37 Special Topic – The Pharmacy Package (File 50 Series) Where are the files? File 50 Series is the main line, though there are other places How many files are there? - 437 Look at screen capture on next side for File 50 series. How many columns? - 3174

38 How Many File 50 Tables Are There? (1096 – 659 = 437 Tables!!)

39 How Many File 50 Series Columns Are There? (8526 – 5352 = 3172!!)

40 Further Information On The Background For the VA Base M Training ault.htm ault.htm For the VA Programming Standards and Conventions For the VA Document Library

41 Computerized Patient Record System (CPRS) A Real-Time Order Checking System that alerts clinicians during the ordering session that a possible problem could exist if the order is processed A Notification System that immediately alerts clinicians about clinically significant events A Patient Posting System, displayed on every CPRS screen, that alerts clinicians to issues related specifically to the patient, including crisis notes, warning, adverse reactions, and advance directives The Clinical Reminder System, which allows caregivers to track and improve preventive health care for patients and ensure timely clinical interventions are initiated Remote Data View functionality that allows clinicians to view a patient’s medical history from other VA facilities to ensure the clinician has access to all clinically relevant data available at VA facilities CPRS DOES NOT STORE DATA!!!

42 CPRS Internals Written in Embarcadero Delphi (NOT in MUMPS) Connects from the Graphic User Interface to the VistA database using a Remote Procedure Call (RPC) Broker This Remote Procedure Call Broker translates instruction sets from other languages into M

43 Present State of VistA Large MUMPS database Over 50+ Main Clinical Packages Over 10,000 + Tables Each medical center runs somewhere between 2-4 TB worth of data over 30 years (mostly imaging) Many processes 300+ MB of running executable at any given time Over 20,000 subroutines (VDL) Many simultaneous users

44 The VA Data Lifecycle

45 National Analytic Systems A list of systems that support policy, planning, and congressional needs There are more extracts than this, but I have chosen the most common ones…

46 46

47 Systems to Support Planning Decision Support System (DSS) Supports accounting and costing for the OIG, GAO, CBO, and other auditing agencies Allocation Resource Center Supports personnel and resource allocation at the medical center level Workload capture, resource allocation Basis for the VERA (VA’s Fund Control Point) Model

48 VistA DSS Data Feeds ADMAdmissionsCLIClinic Visits DEN DentalECSEvent Capture System IVPPharmacy: IVLABLab LARLab ResultsMOVPatient Movement – Inpatient MTLMental Health TestNURNursing PASPatient AssessmentPREPharmacy OP PROProstheticsRADRadiology/Nuclear Med SUR SurgeryTRTPatient Treatment Specialty UDPPharmacy Unit Dose IP May be transmitted by site at any time of the month, ideally around the 25 th of the month prior to the processing month.

49 Systems to Support Research National Patient Care Database An integrated set of data that captures a patient’s care encounter with the VA Corporate Data Warehouse – A near real-time accumulation of much of the same data The result of the Health Data Repository process

50 NPCD Data Flow Diagram Data extracted & backed up nightly M-F DMI Data received in DMI 24x7 NPCD data is sent from the facilities to the AAC via MailMan messaging MailMan Message VistA MailMan NPCD and other applications retrieve their respective data from DMI for use Data Stream Once a message reaches the AAC MailMan server, It automatically moves to the Data Management Interface System (DMI) Austin MailMan Server Acknowledgement messages are sent to facilities HL7 data to Oracle DB Acknowledgement message z900 NPCD Data extracted by application

51 NPCD Processing DSS data extracted Flat files are indexed and loaded into the database daily Data is checked for duplicates bi- monthly Data is extracted and filtered for reporting twice a month Oracle on Unix NPCD UNIX Master Extract File (MEF) SAS z900 (MAINFRAME) VSSC/ KLF Menu WINDOWS Daily Data Loading

52 Resources for Further Information VA Information Resource Center (ViREC) National Patient Care Database – (Internal) National Data Systems (NDS) (Internal)

53 Secrets of the VA Data Universe This was an extremely brief introduction to a complicated area I have another presentation on the availability of databases in the VA and how to access them for operations and/or research

54 The VA Data Lifecycle

55 Regional Remote Data Processing Center Shadow Systems A offsite backup process to ensure continuity of operations for VistA Patient Care

56 Regional Data Processing Centers (RDPCs) Read only backup VistA systems are set up to take journaling files When a record is written or altered to a local medical center’s VistA, a journal file with that entry is prepared and sent to a Regional Data Processing Center This maintains an active backup in case the local medical center’s VistA goes down VistA goes down OpenVMS goes down

57 Regions and RDPCs Region I RDPC – Sacramento (SAC) and Denver (DEN) Region IV RDPC – Philadelphia (PHI) and Brooklyn

58 The Day VistA Died

59 Northern Cal Without VistA The medical staff was forced to write discharge instructions and notes on paper. The electronic lists of instructions and of medications were not available for the patients being discharged. Patients being discharged could not be given follow-up appointments at the time of discharge. The appointments had to be made later and the patient notified by phone. There were delays in obtaining discharge medications and patients remained on the wards longer than would normally be required. The nurses administered medications to the patients and used the paper Medication Administration Record, or MAR, to record the administration events. Initial medication passes were interrupted and delayed until the paper copies of the (MAR) could be printed.

60 RDPC Denver and Brooklyn

61 The VA Data Lifecycle

62 Business Intelligence

63 Business Intelligence in the VA – Making the Data Work For Us VistA has a wealth of clinical and administrative data available In the past, giving a value-added, timely VistA dataset was hard Querying the active system with minimal impact Needed an interface between M and analyst languages (SAS, SQL, etc.) Easy to read reports was hard to build


65 Corporate/Regional Data Warehouse Takes a copy of the journal file that goes into the backup shadow system Translated from the M array to a relational database format using Intersystems Cache’s class mapping program Staged in a Feeder-Collector system for collection Indexed and value-added columns produced and loaded to an VISN RDW Server

66 CDW Governance VHA Business Owners/SME’s VHA-OI Data Quality OI&T Corporate Data Warehouse 10N, OIA, VBA CDW Governance Board Communicates Organizational Priorities Organizes SMEs and Data Stewards Provides Documentation and Clarification of Business Logic Sets and monitors domain, work priorities, and timelines for completion.

67 CDW Governance Is In VHA’s Hands Ordered By VHA Domain and Work Prioritization By CDW Governance Board Chair – KLF (OIA) Vice-Chair – Larry Mole (Public Health SHG) Monitored and Accountable To VHA Project management provided by John Quinn (National Data Systems) and KLF (OIA) Supported By VHA OI Data Quality Business Owners PBM’s Data Steward is Rob Silverman

68 “As the number of eyes goes up, the number of bugs goes down.” Writing documentation about the business logic of the files and fields Answering end user questions about the data Data validation Preferably before Inpatient Pharmacy ADR/Allergy Package

69 1 st category models are simple – V Health Factor Source Mapping FMFileFMFieldResolveFldDWTableNameDWFieldName V HEALTH FACTORSHEALTH FACTORHealthFactorHealthFactorTypeIEN V HEALTH FACTORSHEALTH FACTOR0.01HealthFactorHealthFactorType V HEALTH FACTORSPATIENT NAMEHealthFactorPatientIEN V HEALTH FACTORSEVENT DATE AND TIMEHealthFactorEventDateTime V HEALTH FACTORSVISIT0.01HealthFactorVisitVistaDate V HEALTH FACTORSVISIT0.01HealthFactorVisitDateTime V HEALTH FACTORSLEVEL/SEVERITYHealthFactorLevelSeverity V HEALTH FACTORSVISITHealthFactorVisitIEN V HEALTH FACTORSENCOUNTER PROVIDERHealthFactorEncounterStaffIEN V HEALTH FACTORSCOMMENTS HealthFactorComments

70 2 nd category models require transformation – Prescription Prescription and 1 st fill Refill Prescription Only All Fills Partial Fill Fileman Data Warehouse

71 3 rd category models not usable without transformation - PCMM

72 Levels of Data National – Corporate Data Warehouse (CDW) Region – Regional Data Warehouse (RDW) VISN – VISN Data Warehouse (VDW) Medical Center – Local Data

73 Entities Who Produce Business Intelligence Products National – VSSC, PSSG, DMDC, HEC, ARC, DSS, BIPL, OQP, PCS, PBM Region – Regional BISL Teams VISN – VISN Data Warehouse, VISN PBM Local – DSS Bolded are ones that have substantial resources in clinical business intelligence PSSG handles much of the GIS and Statistical Demography for the VA

74 Data Access VISN and Station Level – Contact Your VISN Database Manager Regional/Corporate Access – Contact NDS for the 9957 Permissions

75 Operational Challenges of VistA System Resources $8 Billion investment over 20 years New needs for new domains MUMPS Programmers must be internally trained (and many of them are retiring or dying) Communication with Other Systems HIMISS compliance with data interchange E-functions (billing, prescribing, verification) Interagency Cooperation – DoD and NHIN Business Intelligence Closing the data lifecycle and bringing back clinical data for knowledge discovery

76 Why Is Pharmacy ALWAYS Picked As An IT Test Case Project? Pharmacy is data savvy Local data quality control from ADPACs Federated data quality control from VISN PBM, CMOP, PBM SHG Pharmacy is one of the few domains that have active business logic SME’s Pharmacy did not contract institutional memory out the door Pharmacy gets things done Pharmacy has more technology success stories as a collective than any other PCS office (BCMA, Automation, Central Fills) Pharmacy actively mines data

77 Acknowledgments Kernel – Jack Schram (Oakland OIFO) SQLI – Ellen Zufall (SF IRMS) RPC Broker and MUMPS coding – Perry Richmond (VISN 18 BI) Regional Data Process – Vincent Bui and Ken Koenig (Region I SQL Back Office Team)

78 Acknowledgments OI&T Business Intelligence Product Line (BISL) Jack Bates – Manager, OI&T BIPL Stephen Anderson – Lead Data Architect Mike Baker – Lead ETL Architect Denver Griffith/Ken Fuchsel – Server Administrators Dave Fackler Ron Talmage Dan Hardan, Jeff King, Jeff Price

79 Questions

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