1. Where Interoperability is Between DoD and VA and VistA Evolution
Presentation to Open Health Tools
Theresa Cullen, MD, MS
Chief Medical Information Officer, VHA
Acting Deputy Director DoD/VA Interagency Program Office
Director, Health Informatics
Office of Informatics and Analytics
Veterans Health Administration
Department of Veterans Affairs
SEPTEMBER 27, 2013

2. Agenda Interoperability Overview
Department of Defense (DoD) / Department of Veterans Affairs (VA) Interagency Program Office (IPO) Role in Interoperability
Janus Joint Legacy Viewer (JLV)
Virtual Lifetime Electronic Record (VLER) Health
Veterans Health Information Systems and Technology Architecture (VistA) Evolution

3. Interoperability Overview

4. What is Interoperability?
Interoperability refers to the relationships between systems, information, and people required to provide outstanding health care and benefits for our Servicemembers and Veterans.
Systems include the infrastructure and equipment needed to store information and move it from place to place
Information includes all the data, from all useful sources, needed for providing and receiving care and benefits
People include clinicians and other providers, claims processors, transition coordinators, etc., as well as the Veterans and Servicemembers providing or receiving care and benefits

5. Three Key Interoperability Relationships
Relationship #1 – Technical Interoperability
Information must be reliably exchanged between multiple Systems so People in different places and organizations can see it, use it and add to it
Relationship #2 – Semantic Interoperability
Information exchanged between Systems must have shared meaning in order for People (assisted by computers) to use it for making care and benefits decisions
Relationship #3 – Process Interoperability
People (assisted by computers) must be able to make use of shared Information in their local workflows and processes for providing and receiving care and benefits

6. Seamless Interoperability for Care and Benefits
Technical Interoperability
Information Exchange
Semantic Interoperability
Shared Meaning
Process Interoperability
Workflow Continuity
Seamless Interoperability
is Technical, Semantic and Process Interoperability together

7. DoD/ VA IPO Role in Interoperability

8. Proposed i3P – a Foundation for Seamless Interoperability
The integrated Electronic Health Record (iEHR) Informatics Integration and Interoperability Platform (i3P) will be an inherent cross-platform capability between VA and DoD health information systems, creating a seamless, interoperable, longitudinal health record for Servicemembers and Veterans.

9. What Will i3P Do?
Federate data from legacy and future DoD and VA Electronic Health Record (EHR) and related business systems
Enables interoperability relationships between old and new health information technology (HIT) Systems, Information and People from all critical DoD and VA health data domains
Aggregate, store and index eHealth Exchange data used by VA and DoD providers in clinical decision making
Facilitate decommissioning of several complicated and expensive legacy VA-DoD health data sharing mechanisms in Fiscal Year
Provides a shared platform for data federation, clinical terminology, access management, patient identity, and support for clinical decision services for VA and DoD
Enables decommissioning of Clinical/Health Data Repository (CHDR), most Bidirectional Health Information Exchange (BHIE) SHARE and Framework components, jMeadows, Medical Domain Web Services (MDWS), VistAWeb, and consolidation of DoD and VA Virtual Lifetime Electronic Records (VLER) Adapters

10. Janus JLV

11. Janus JLV Features
Janus JLV provides an integrated read-only view of health data from DoD and VA sources in a common viewer.
An important stepping stone toward modernizing our VA and DoD health information systems, JLV will support care of our Wounded Warriors and Veterans by improving access to electronic patient records and reducing the need to transfer information by fax, mail, or CD.
Features
Web-based Graphical User Interface
Integrated, chronological view of VA and DoD patient data on a single screen
Displays progress notes, problem lists, labs, vitals, immunizations, allergies, medications, Essentris inpatient discharge summaries (DoD), and radiology
User friendly, configurable screen layout
Easy to learn, intuitive user interface
Benefits
Simplifies review of patient records, returning valuable time to providers
Will reduce printing, scanning , and faxing of paper records
Designed to support frequent enhancements and upgrades

12. Janus JLV Usage: May – August 2013

13. Janus JLV Proposed FY14-16 Mission and Objectives
Janus JLV Mission
Janus JLV provides an integrated view of health data from DoD and VA sources in a common viewer. Janus JLV will continue to simplify the review of patient records, will reduce printing, scanning and faxing of paper records, and supports both clinical and benefit adjudication activities in the DoD and VA.
FY14 Proposed Objectives
Display of normalized data for seven Accelerator domains + i3P Block 1 and 2 domains as available on path to enable retirement of legacy systems
Incorporate eHealth Exchange functionality to enable VistAWeb retirement
Healthcare Artifact and Image Management Solution (HAIMS)/VistA Imaging viewer and doclist widgets
Integrate with iEHR Document Management System (DMS) (including terminology service)
User Interface and usability enhancements based on customer requirements
Capacity for up to 40,000 concurrent users
Expand footprint at Military Health System (MHS) Enterprise Service Operations Center (MESOC), Austin Information Technology Center (AITC) and two regional Defense Information Systems Administration (DISA) Defense Enterprise Computing Centers (DECCs) to provide for additional capacity, load balancing and fail-over.
FY15/16 Proposed Objectives
Sustainment
Complete incorporation of Block 2-4 domains as needed (may not be needed if superseded by Healthcare Management System Modernization (DHMSM) or VistA 4 viewer)
Development as required for specific customer needs (i.e., enhancements requested by Veterans Benefit Administration (VBA) or National Guard users)
Work to transition JLV viewer features into DoD DHMSM and VA VistA 4 applications

14. VLER Health

15. VLER Health eHealth Exchange
Presidentially directed lifetime, Electronic Health Record
“VLER Health” provides private sector electronic data
Standardized data transported per national specifications
Nationally scalable technology
High value content (C32, C32+, Consolidated Clinical Documentation Architecture)
VLER Health to provide data “to and from”
iEHR data management services
Pilot the “Direct Project”
Expand eHealth Exchange Sites
High Impact Partnerships
Other Health Information Exchange
Trusted Agreements,
Scalability through Testing
Support Benefits Claims
In the spring of 2009, President Obama announced plans to create a joint Virtual Lifetime Electronic Record (VLER) to improve care and services between the Department of Veterans Affairs (VA), Department of Defense (DoD), and the private sector. VLER will allow health care providers access to Veterans’ and Servicemembers’ treatment records in a secure and authorized way, regardless of whether care is delivered in the private sector, at military treatment facilities, or at VA medical centers.
One aspect of VLER leverages the Nationwide Health Information Network to allow for the secure exchange of health information between the Department of Veterans Affairs, the Department of Defense, and the private sector.
The benefits that we hope to realize include providing real time access to critical health information needed at the point of care, eliminating the need for patients to hand carry copies of their health records from provider to provider.
In addition, access to shared health information has the potential to reduce duplicate tests and procedures as well as reducing the potential for adverse events related to drug/drug interactions for patients receiving multiple prescriptions from various sources.
eHealth Exchange
Membership organization: Successor to the Nationwide Health Information Network or NwHIN which was developed by the Department of Health and Human Services Office of the National Coordinator for Health Information Technology to establish a national exchange
Supported by Healtheway, Inc., a public-private 501c(3) corporation that oversees testing and onboarding
Core capabilities
Supports harmonized standards
Supports common trust agreements
Supports secure information exchange
Supports consumer preferences regarding the exchange of information
Matches patients to their data without a national patient identifier
Delivers a summarized patient record to support patient care (C32 Continuity of Care Document – Consolidated Clinical Document Architecture)

16. VLER Health Exchange “Query” Expansion
Successes
Sites that pre-fetch, send all data
Challenges
ID matching, data quality, coded data, use of full C32, automated onboarding, and Information Technology Adaptor contracts
Pilot Site
Exchange Partner
DoD/VA
Began Exchange
San Diego, California
Kaiser Permanente (KP)
12/14/09
San Diego Beacon VA
11/30/2011
Hampton, Virginia
MedVirginia
9/15/10
Richmond, Virginia
3/25/11
Spokane, Washington
Inland Northwest Health Services (INHS)
Asheville, North Carolina
Western North Carolina Health Network (WNCHN)
4/4/11
Indianapolis, Indiana
Indiana Health Information Exchange (IHIE)
8/22/11
Puget Sound, Washington
MultiCare Health Systems
9/30/11
Buffalo, New York
HEALTHeLINK
Minnesota, Minnesota
Community Health Information Collaborative (CHIC)
Charleston, South Carolina
South Carolina Health Information Exchange (SCHIEx)
10/3/11
Salt Lake City, Utah
Utah Health Information Network (UHIN)
Grand Junction, Colorado
Altoona, Pennsylvania
Conemaugh Health System
4/1/12
Boise, Id
Idaho Health Data Exchange
2/7/13
Pensacola, Florida/Biloxi, Mississippi
Pensacola Health Information Exchange
4/24/13
Current Laydown of joint and VA only implementation sites
VLER Health Site Selection
IPO and Departments have established site selection criteria to implement the JEC decision:
High volume of potential exchanges
High volume of private sector care for Veterans and/or Service members (and DoD non-active duty beneficiaries in the future)
Exchanges have high value for VA and DoD clinicians
Private sector Health Information Exchange (HIE) partner is capable of exchanging clinically relevant health information with a high value electronic Summary of Care document
Mature Private Sector Health Information Exchange Partner
Private sector HIE uses health information technology standards and trait matching criteria to achieve a high percentage of correlated shared patients
Emphasize filling gaps to promote regional health exchange
Examples: Southeast, Intermountain West

17. VistA Evolution

18. Background
In 2013, VA and DoD Secretaries made decisions that require a change in EHR strategy
The VA EHR 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’

19. Current VA Landscape
eHealth
Currently, our EHR and Health Information Technology (HIT) systems are disconnected and fragmented
Connected Health
Janus JLV
VistA Web
VistA
CPRS
iEHR
This impacts our ability to deliver on the mission - excellent quality, access, satisfaction, and value
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/HIT Landscape

20. VistA Evolution and VistA IV
VistA Evolution is the VHA program that will support this strategic plan through continual investment and delivery of scalable and modular EHR and HIT products.
VistA IV is the infrastructure and open and extensible platform on which tools and services can be integrated in support of our Veterans evolving needs and in pace with the technological landscape.
The VistA Evolution Program
Plan Version 1 provides an overview of VA’s effort to deploy VistA enhancements to achieve an Initial Operating Capability (IOC) by September 30, 2014
The VistA Evolution Program Plan Version 2 is scheduled for completion by October 31, 2013 and will provide an overview of the efforts to achieve FOC by September 30, 2017
Upon completion in FY2017, the VistA Evolution Program will deliver a 4th generation
VistA (VistA-4)
Is a combined functional, technical, and programmatic approach to promote effective, safe, and efficient healthcare delivery to Veterans
Will support the VHA track record as a benchmark of excellence and value in health care delivery
Will support delivery of services that are both patient-centered and evidence based consistent with VHA and federal healthcare goals
Will support care coordination—where collaborative teams work together to include the patient in addressing the Veterans’ healthcare needs

21. VistA Standardization
VistA Evolution
Beginning in Fall 2013, we will analyze and synthesize existing platforms into the new platform – VistA IV
VistA IV
Connected Health
VistA
A single viewer will become the starting point for a new User Experience to support PACT, patients, and the population
CPRS
CAPRI
VistA Web
RDVs
HMP
Janus JLV UX
VistA Standardization
DoD
iEHR
Acronyms
CAPRI – Compensation and Pension Record Interchange
CPRS – Computerized Patient Record System
DoD – Department of Defense
HMP – Health Management Platform
iEHR – integrated Electronic Health Record
JLV – Joint Legacy Viewer
PACT - Patient-Aligned Care Teams
RDV – Remote Data View
UX - User Experience
eHealth

22. VistA Evolution Initial Operating Capability (IOC): Fiscal Year 2014
A joint VHA – VA Office of Information Technology VistA Evolution Program ‘Execution’ Office will be responsible for delivering IOC.
Delivered to at least two sites - Hampton Road and San Antonio
IOC Infrastructure and Functionality Include:
VistA Standardization
Certify standardization of 74 VistA application routines in production
Immunizations
Modernize VistA immunization file
Read/write/exchange clinical decision support
Bidirectional immunization sharing
Potential sources of adoption: VA Innovations, OpenCDS, IHS Resource and Patient Management System (RPMS)
Laboratory Information System Acquisition
Clinical User Experience Tools
‘Google-like’ Search
HL7 Context-Aware InfoButtons
Medication Review ‘widget’
Integration with iEHR Interoperability Platform

23. VistA Evolution 2017
VistA IV
Federal Partners (DOD, IHS)
By 2017, we
will have an architecture and framework that supports interoperability, care coordination, meaningful use and partnership
Integrated Architecture
and Services
Interoperable
User Experience
VBA
Care Coordination Framework
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

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