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

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

Interoperability Overview

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

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

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

DoD/ VA IPO Role in Interoperability

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.

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 2015-2016 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

Janus JLV

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

Janus JLV Usage: May – August 2013

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

VLER Health

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)

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

VistA Evolution

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’

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

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

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

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

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

Questions? Contact Information: Theresa Cullen, M.D, M.S. Theresa.Cullen@va.gov