Presentation on theme: "Big Data and VistA Evolution"— Presentation transcript:
1 Big Data and VistA Evolution Presentation to Open Source Electronic Health Record Alliance (OSEHRA) Architecture Work GroupTheresa A. Cullen, MD, MSChief Medical Information OfficerDirector, Health InformaticsOffice of Informatics and AnalyticsVeterans Health AdministrationDepartment 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 FamilyPopulationPatientCommunity... . .
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 Centers990 Outpatient Clinics Community-Based Hospital-Based Mobile Independent300 Vet CentersID:15Created for VHA Overview Version 1.6/13/2011Updated 1/22/2013 to reflect FY th Quarter pocket card:70 Mobile Vet Centers102 Domiciliary Residential Rehabilitation Programs134 Community Living CentersSource: FY 2012 End-of-Year Pocket Card
6 VA’s Health Care Delivery Model Personalized, Proactive and Patient-DrivenTeam CareContinuous ImprovementData-Driven, Evidence-BasedValuePrevention / Population HealthID:23Created for VHA Overview Version 2.7/18/2011Edited 1/10/2013 Coordinated Care
8 Collect and Blend the Big Data CUTMIXDICEBLENDJapan and connectedness.. Finish with story and a quote and the Blender pictureComment about letting people in on the freewayPARSE
9 Secondary Data Use: Research and Predictive Analytics Capabilities Providers can’t accurately predict Veterans at highest risk of deteriorationPatient Aligned Care Team Registered Nurse (RN) Care Managers charged to coordinate careNo systematic way to identify Veterans who might benefit most predictive analytics using data from Electronic Health Record (EHR)Home-based primary careCase-managementSpecialty clinics, e.g., heart failureTelehealthPalliative careBroad range of clinical programs designed to improve care for Veterans with complex chronic illnessVHA provides a broad range of programs for patients with chronic illness to improve outcomes and prevent hospitalizations:Home-based primary careCase-managementSpecialty clinics, e.g., heart failureTelehealthPalliative careHowever, no systematic way of targeting programs or identifying patients who might benefit mostKnowledge 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 benefitDoctors and nurses cannot accurately predict who is at highest risk of deteriorating or dyingPredictive 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 domainsMeds, Labs, Rad, Notes, Diagnoses, etc.Results in bad thought-flow and workflow
11 Moving From What’s Wrong Data SilosData JuxtapositionData + Workflow Integration
12 Implications of Conceptual Approach Goal - construct user-interface components to facilitate clinical reasoning and workAddress basic cognitive needs – then reuse or reconfigure for most health care processesAvoid “an app for that,” while allowing for extensibility
14 Developing Context-Sensitive Orders 30 million records – 20 years of data mined to identify relationships betweenProblemsLaboratory resultsPrescriptionsProceduresOrdersLocationProviderPatient15,000 conditions and 10,000 orders
15 Common Test and Drug Orders Epigastric painCBC with diffChemistry panelHelicobacter pyloriLipaseAmylaseUpper GI endoscopyAbdominal ultrasoundCT abdomen w/o contrastOmeprazoleRanitidineAmphogelRabeprazolePromethazineSucralfateMetronidazoleMetoclopramideDocusate
16 Characteristics of VHA Analytic Approach Treat corporate data as strategic resource, available to entire organizationMaximize understanding of organizational processes and outcomes to promote learning and improvementInvest 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 toolsFor leadershipUnderstanding organizational performance and vulnerabilitiesFor public/consumersUnparalleled 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 assessmentProvides patient level detailAccessible through VHA Support Service Center (VSSC) website and Computerized Patient Record (CPRS) tools menuFor primary care providers, and/or nurse care managerModel 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 efficiencyCollaborate 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 supportEnhance analytic skills throughout Veterans Health Administration (VHA) workforcePromote transparency and accountability
21 BackgroundIn 2013, VA and Department of Defense (DoD) Secretaries made decisions that require a change in EHR strategyThe VA EHR core will be VistA-basedOur mission has not changed“to care for him who shall have borne the battle, and for his widow, and his orphan”
22 Current VA LandscapeVLER HealthConnected HealthOver the past several years, various products have been developed across the VA landscape, creating a complex suite of applicationsJanus JLVVistA WebVistACPRSiEHRRDVsCAPRIVistA StandardizationHMPAcronyms:CAPRI – Compensation and Pension Record InterchangeHMP – Health Management PlatformiEHR – integrated Electronic Health RecordJLV – Joint Legacy ViewerRDV – Remote Data Views‘Conceptual’ representation of currentEHR/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 CriteriaInteroperabilityFull Operating Capability (FOC)2014201520162017
24 VistA Evolution Management Approach Continuous feedback and improvementEngaged customers and stakeholdersJust in time requirementsAn 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 ManagementFeature Driven DesignAgile PrinciplesFocuses on system behavior and usabilityRequires some system modeling and design upfrontPlan 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:InteroperabilityImplementation of an open and extensible EHR systemEstablishment of interoperability between VA and DoD EHR systemsRe-engineering of business processes in collaboration with users of health IT
26 VLER and IPO define the interoperability standard VistAFederal 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 hospitalsIntegrated Architectureand ServicesUser ExperienceVBACare Coordination FrameworkVLER and IPO define the interoperability standardVisionA user experience that integrates information for improved quality and effective clinical decision takingMulti-provider information sharing tailored to the patient's clinical condition, care goals, and physician best practicesProvides 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 populationManagement of activities that improve human and material resource utilization and clarify plans of careExplicit incorporation of patient goals in the care plan, to support patient-defined terms of successEnterprise-wide deploymentStandard Data ModelOpen Source/Community PartnersAcronyms:DoD – Department of DefenseIHS – Indian Health ServiceVBA – Veterans Benefits Administration
27 Three Key Interoperability Concepts Technical (syntactic) InteroperabilityAllows computers to reliably exchange data, so it can be read at least by humans.Accomplished with messaging protocols and data formats.Semantic InteroperabilityAllows computers to unambiguously and consistently determine meaning of the data for presentation and decision support.Accomplished with standardized terminologies like ICD10 and SNOMed.Process InteroperabilityAllows 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-rayEx. 3: continuing polytrauma care plans as patients move between VA and DoD.
28 How Do We Get to Seamless Interoperability ? PrinciplesMapping to National Standards is the correct approachVA 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 accuracyThe possibility and degree of harm 100% mediation is NOT to be expectedMediation 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 EvolutionImprove technical infrastructure for health data interoperability while reducing overall system complexity (improved syntactic interoperability)Convert to standards-based services, formats, protocols, and data modelsEnable 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 functionsConsensus 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 ProgramManagement ApproachGovernance for Program Planning, Change Control, and Risk ManagementVistA Evolution Product ApproachEHR Certification and Meaningful UseRequirements Management StrategyCommunications StrategyTraining StrategyTransition StrategyWork 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 DoDTie together disparate threads of clinical data into one care coordination plan available to the entire clinical care teamDeliver the greatest quality of care that supports the health status goals of Servicemembers, Veterans, and family membersWill 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 VisionIdentify Projects and TeamsCreate ModelsEnvisionDetermine user needs from real, actual usersDevelop user personas and scenariosInvestigate pain points in current systemInvestigate options for meeting user needsInvestigate process toolingSpeculateOrganize user needs into Features and Feature GroupsDevelop multiple designs for FeaturesDesign and test Throw Away prototypes with real usersCreate lightweight Real prototypes of the best designsAdds/Cuts on selected designsCreate lightweight specs for developmentExploreWrite code and implement specsTest features for code qualityTest features against scenarios with real usersIntegrate with other Feature Groups and SystemAdaptDeliver productPass along key learning'sCelebrateCloseAllows for substantial upfront design and iteration and evolution in developmentThis is needed to deliver features requiring highly refined design for User Interface (UI)/User Experience (UX) controls, layout, and interaction
37 VistA Standardization VistA EvolutionVistA EvolutionProductVistA legacyConnected HealthVLER HealthCPRSCAPRIVistA WebRDVsHMPJanus JLVVistA StandardizationDoDiEHRBeginning with delivery of new features by September 2014, we will analyze and begin to synthesize existing features into a new platformA single viewer will become the starting point for a new user experience to support Patient Aligned Care Teams, patients, and the populationAcronyms:HMP – Health Management PlatformJLV – Joint Legacy ViewerRDV – Remote Data Views
38 VistA Evolution Initial Operating Capabilities (IOC): September 2014 Capabilities enabled at two sites: Hampton Roads and San AntonioAdvanced User Interface Tools (via Health Management Platform)‘Google-like’ Search across databaseHL7 Context-aware ‘InfoButtons’ integrated into User InterfaceMedication review toolVA/DoD Information Sharing (via Joint Legacy Viewer)ImmunizationsModernize VistA immunization files, incorporate required ‘CVX’ formatFacilitates enabling of read/write/exchange + advanced CDS in FY15Enables new sources of adoption: VA Innovations, OpenCDS, IHS RPMSLaboratory Information System AcquisitionModernization and automation of ‘back-end’ lab processesFacilitates data exchange , business process interoperability, and enhanced CDSVistA StandardizationCertification of 74 standardized VistA application routines in production (complete)
39 ONC 2014 Edition Certification of VistA ONC 2014 Edition Certification CriteriaVA intends to certify 46 criteria by September 30, 2015The 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.