The Importance of Dynamism in the OpenVistA Model Chris Richardson & David Whitten WorldVistA http://www.worldvista.org June 16, 2005

WorldVistA Nonprofit, 501(c)(3) public-benefit corporation Seeks to improve health worldwide by making medical software more accessible, more affordable, and better. Members include Developers working, or who used to work, for U.S. DVA OpenVistA end-users Other organizations members or representatives Promote VistA Open-Source Future development coordination Including “localization” and “internationalization”… Change management & licensing Inter-institutional arrangements and coordination End-User and Developer Education & Training

What is VistA? Most integrated Health Information Technology (HIT) system in the world Integrated outpatient and inpatient information with local flexibility and innovation 100+ Modules Used by over 100,000 users worldwide Including 1,300+ VA facilities; in 20+ care networks 170+ Hospitals 650+ Outpatient Clinics 25+ Million Veterans - 20% some receiving care in more than one facility/location Shows List of Sites with Last Treatment Date Displays CPRS Reports from VHA Facilities Home Care, Long-term Care Facilities, etc…

What is VistA? HIT built on standard, industrial strength technologies Leverages and supports Open Source software community Architecture Client GUI for critical and timely data access at all levels Terminal-interface available for power-users. Security Secure communications between client and servers Database From FOSS (GT.M) to commercial offerings (Caché) Platform managing millions of patient records for decades Blazingly-fast data stores Up to 20 times faster than RDBMS and SQL… Operating Systems and Hardware From “big iron” to commodity 32 and 64-bit hardware platforms From Windows to Unix/Linux servers

What is VistA? Multimedia Patient Records Text Computable data Handwritten and non-electronic data Via “scanning” Other multimedia data accessible… Radiology images EKG waveforms Other medical images pathology slides, endoscopic views, dermatology photos, … Video clips echocardiogram, cardiac cath films, barium swallows, gait analysis, … No double-entry of information 5

What is VistA? Simultaneous user accesses Remote access when needed No loss of patient information Contains “traditional chart components” such as: Progress Notes Orders Procedure Reports Discharge Summaries Problem Lists Lab Results Vital Signs 6

What is VistA? Supports “other chart components” such as: Annotated Diagrams - Stick Figures Advanced Directives Consent Forms Flowsheets Admission and Referral Forms Reports from other medical facilities Augments chart components with: Automated alerts for allergies, directives Periodic Clinical Reminders Inpatient Status and Location Outpatient Appointments 7

What is VistA? Enterprise-wide source for Patient ID with business rules Advanced “Master Patient Index” (MPI) With consolidation capabilities for duplicate records Access of patient medical information stored in other facilities Powerful toolkits For database and client/server Multiple programming languages Java Visual Basic Visual C++ Apache/CGI Delphi …and more to come 8

Why Use VistA? Modular Improves quality of care Allows data to be… Allows tailoring for the needs of any healthcare organization Improves quality of care Provides ALL patient data in one easy-to-access repository Facilitates communication among caregivers Allows data to be… Entered at the point of service Shared among different sites and/or providers Continuity of inpatient & outpatient records Reduces cost Eliminates duplicate-orders Reduces time spent searching for patient information Eliminates redundant record-keeping Simplifies data-collection for research and reporting 9

Why Use VistA? Reduces errors due to lack of data or poor handwriting Increases patient safety Provides enhanced data privacy and security protections. Automated Clinical Support… Clinical reminders (prevention, treatment,…) Alerts (notifications to clinician about real time issues) Scheduled and un-scheduled batch processing Tracks consults and orders from requests to results 10

Why Use VistA? 11 Adheres to National HIT Standards “Consolidated Healthcare Informatics” (CHI) Initiative DICOM Retrieval and transfer of images and associated diagnostic information HL7 Demographic information Units of measure Immunizations Clinical encounters Clinical Document Architecture for text- based reports LOINC EDI of clinical laboratory test orders EDI of clinical laboratory results Drug label section headers HIPAA ANSI X 12N Billing and Financial Standard Transactions NCPDP Retail Pharmacy Transactions CPT, HCPCS, ICD-9, NDC,… Standard Code-sets SNOMED CT Laboratory result contents Non-laboratory interventions and procedures Anatomy Diagnosis and problems, and Nursing IEEE 1073 Connect medical devices to information and computer systems Allows monitoring of information remotely FDA Names and codes for ingredients Manufactured dosage forms Drug products Medication packages NLM RxNORM Describe clinical drugs VA National Drug File Reference Terminology (NDF-RT) Drug classifications 11

Why Use VistA? Open Source / Public Domain Fully-functional Free (unless implemented on top of a commercial database) Significantly reduces Total Cost of Ownership (TCO) Fully-functional Fully-integrated HIS, RIS, LIS, PACS, … Enterprise-wide National-scale Multiple sources of support NOT proprietary… NOT tied limited support sources for an extended period of time… 12

Some VistA Components 13 Clinical Functionality Laboratory Adverse Reaction Tracking Clinical Reminders Consults/Request Tracking CPRS Dentistry Dietetics Health Summary Hepatitis C Extract Home Based Primary Care Imaging & Multimedia Immunology Case Registry Inpatient Medications Including Intravenous, Unit Dose, etc. Intake and Output Laboratory Including EDI, Anatomic Pathology, Blood Bank Lexicon Utility Medicine Clinical Services Mental Health Nursing Oncology Outpatient Pharmacy Patient Care Encounter Patient Information Admission, Discharge, Transfer, Registration 13

Some VistA Components 14 Clinical Functionality (cont.) Pharmacy Automatic Replenishment / Ward Stock Bar Code Medication Benefits Management (PBM) Controlled Substances Data Management (PDM) Drug Accountability / Inventory Electronic Claims Mail Out Pharmacy National Drug File Outpatient Pharmacy Prescription Practices (PPP) Primary Care Management Problem List Prosthetics Radiology/Nuclear Medicine Remote Order Entry Social Work Spinal Cord Dysfunction Surgery Including Risk Assessment Visual Impairment Vitals/Measurements Women's Health … 14

Some VistA Components 15 Administrative Library Master Patient Index Authorization/Subscription Utility Automated Information Collection System Automated Medical Information Exchange Automated Safety Incident Surveillance Tracking System Decision Support System Extracts Duplicate Record Merge: Patient Merge Engineering Equipment/Turn-In Request Event Capture Incident Reporting Library Master Patient Index Including Demographics Network Health Exchange Occurrence Screen Police and Security Record Tracking Resident Assessment Instrument Scheduling Survey Generator Voluntary Timekeeping … 15

Some VistA Components System 16 Remote Procedure Call Broker FileMan Kernel Kernel Installation and Distribution System (KIDS) Kernel ToolKit MailMan SQL Interface (SQLI) Health Level Seven (HL7) Patient Data Exchange (PDX) National On-Line Information Sharing Patch Module Remote Procedure Call Broker List Manager Remote Data Views Victory Programming Environment (VPE) … FileMan is VistA’s DBMS and basic “Toolset”. It allows access to the DBMS via “interactive” (users interact via Dialog Boxes) or “silent” (users send commands without answers) routines, or through a set of utilities; in all modes, it is used to define, enter, and retrieve information from files described by a data dictionary. FileMan provides an API (“Applications Programming Interface”) for MUMPS programmers and because users of the interactive components of Fileman reference the same APIs that programmers do, user interface and results are consistent. FileMan includes features such as: (i) A report writer, (ii) A data dictionary manager, (iii) Scrolling and screen-oriented data entry, (iv) Text editors, (v) Programming utilities, (vi) Tools for sending data to other systems, and (vii) File archiving. For those not familiar with “M”, but rather an SQL RDBMS; we could say that FileMan is a combination of the RDBMS’s “engine” and the RDBMS’s “SQL Interface to the Engine” (which is used by users and programmers alike to access the databases under the control of the “engine”.) Kernel provides a portability layer between the underlying operating system and application code; allowing the entire VistA system being portable among different computers, operating systems, and M implementations. This, together with the database portability provided by FileMan, eliminates the cost of application conversions each time the organization changes its computing platforms. KIDS provides a mechanism to create a distribution of packages and patches, allows distribution via MailMan or a host file, and allows queuing the installation of a distribution for off-hours Kernel Toolkit (also referred to as “Toolkit”) supplements the Kernel, providing Development and Quality Assessment Tools, Capacity Planning Tools, and System Management Utilities. MailMan is an electronic messaging system that transmits messages, computer programs, data dictionaries, and data between users and applications in the same or at different facilities. When MailMan is integrated into an application, it notifies individuals and groups about important events. From FileMan, a change in the value of a field can trigger a message called a “bulletin”. SQLI helps make VA FileMan data available to outside applications via the SQL language. PDX is a VistA module designed to electronically request and receive patient demographics, episodes of care, medications, and diagnostic evaluations from other facilities. Victory Programming Environment (VPE) consists of a number of integrated programmer utilities that will increase productivity and decrease the number of key strokes required to complete normal programming tasks in the VISTA environment. Includes a VISTA-friendly programmer shell with improved routine and global management tools, and an Electronic Data Dictionary that complements and extends the FileMan data dictionary options. 16

CPRS 17

CPRS Computerized Patient Record System Patient centered view of record Dynamically updated client-server architecture Remote Procedure based Centralized updates of functionality Central data storage and validation Efficient code maintenance Graphic User Interface Transparent visualization of patient record Consistent user interface model Separation of View-Model-Controller

Clinical Reminders 19

Clinical Reminders Recommendations, not Practice Standards Disease Screening Immunization Patient Education recommendations Guidelines to assist in clinical practice Appropriate utilization based on clinical judgment patient's current status.

Consult/Request Tracking 21

Health Status 22

Federal VistA Adopters Veterans Administration (VistA) Department of Defense (CHCS) Indian Health Service (RPMS) U.S. Public Health Service NASA 23

US VistA Adopters Washington D.C. West Virginia South Carolina Oklahoma Minnesota Washington City of Berkeley, CA City and County of San Francisco …and more to come 24

International VistA Adopters City of Bogotá, Colombia Germany Egypt Kenya American Samoa …and more to come 25

Recent VistA Embracers Panamá México Japan China Malaysia Jordan India …and still more to come 26

HardHats Virtual community of worldwide VistA users… Historical information about VistA Mailing-list Access to a worldwide community of VistA users Technical Information / Documentation FileMan M Utilities and Information VA Utilities Etc. VistA-distributions VistA under: InterSystems Caché Fidelity GT.M 27

Relationships Between US Government and External Communities Freedom of Information Act Releases Vista Users Distributions U.S. Government Veterans Affairs Health & Human Services WorldVistA Community Collaborative Development Enhancements, Bug Fixes, Etc. Vista Programmers

M Technology MUMPS “Massachusetts General Hospital Utility Multi-Programming System” Also known as “M” Programming language, database management system and related bindings and protocols Predominant world-wide in large integrated hospital information systems. Also successful for systems in financial, travel, shipping, and other industries.

M Technology Main features include: Comprehensive procedural language Support for object-style event-driven processing Integrated hierarchical data management facility Bullet-proof database security and transaction processing Multi-user, multi-tasking operating environment Integrated inter-process communication Support for distributed data and distributed processing High-performance client-server networking capabilities

M Technology (cont) Available with “M” are: Relational data manipulation tools Industry-standard SQL SQL-based connectivity ODBC Interfaces to windowing managers ANSI X3.64 standard support for character devices ANSI GKS standard support for graphics devices

What are Ontologies? Controlled Vocabularies and Taxonomies descriptions built from simpler components broad coverage of data values Formalized Rules and Facts hierarchically arranged categories first order logic formal semantics specialization and generalization classification system dynamic inference rules augmenting system integrated search using rules and facts

How does VistA use Ontologies? Two Answers – both true VistA doesn’t use Explicit Formal Ontologies Long history of development (from 1980’s to present) Implements progressive ontological concepts as available VistA uses Ontologies throughout Many ontological components used Declarative (table driven) strategy is common Hierarchical data structures with inheritance Rule driven methodologies used Expert system used for order checking Controlled vocabularies for workload, diagnosis Permission Security System is rule based

How does VistA use Ontologies? Implicit Ontology based on database definitions and business rules VA FileMan Database has strong modeling capabilities Hierarchical, based on Codd and Date’s original theories Primary focus on clinical and medical information storage Consistency and Integrity maintenance Database elements and user interface consistency Procedural verification and action semantics Declarative (table driven) implementation Cross table and field constraint system

How does VistA use Ontologies Enterprise-wide consistent vocabularies Lexicon based on UMLS National Drug Formulary Ongoing Standardization Process Drug Classes Drug Ingredients Allergy names Packaging, Medical Routes ICD9 DRGs (545 entries) CPT codes /AMA procedures (~17,000 entries) Progress Note Titles and Hierarchy

How does VistA use Ontologies Lexicon based on Unified Medical Lexicon System (UMLS) Table driven Vocabulary system MAJOR CONCEPT MAP (~120,000 entries) CONCEPT USAGE (~120,000 entries) EXPRESSIONS (~153,000 entries) EXPRESSION TYPE (7 entries) EXPRESSION FORM (14 entries) CODES (63,000 entries) CODING SYSTEMS (33 entries) SEMANTIC MAP (~174,000 entries) SEMANTIC CLASS (15 entries) SEMANTIC TYPE (133 entries) SOURCE CATEGORY (487 entries) etc.

How does VistA use Ontologies Hierarchically Driven System User Menu based on Organization’s Functional Areas Role based security Menu Items based on day-to-day actions Graphical Interface (CPRS) Parameters Default values hierarchy individual, department, software subsystem, local hospital Values used for data entry and data presentation Rule driven capabilities Access to resources (orders, consults, progress notes) Students require co-signers Deleting, Modification, Viewing

How does VistA use Ontologies Order Checks Expert System ORDER CHECKS (27 entries) ORDER CHECK COMPILER FUNCTIONS (56 entries) ORDER CHECK DATA CONTEXT (7 entries) ORDER CHECK DATA FIELD (158 entries) ORDER CHECK DATA SOURCE (15 entries) ORDER CHECK ELEMENT (139 entries) ORDER CHECK NATIONAL TERM (14 entries) ORDER CHECK PATIENT RULE EVENT (# entries dependent on site ~300,000) ORDER CHECK RULE (71 entries)

How does VistA use Ontologies Order Checks Expert System ORDER CHECKS (27 entries) ORDER CHECK COMPILER FUNCTIONS (56 entries) ORDER CHECK DATA CONTEXT (7 entries) ORDER CHECK DATA FIELD (158 entries) ORDER CHECK DATA SOURCE (15 entries) ORDER CHECK ELEMENT (139 entries) ORDER CHECK NATIONAL TERM (14 entries) ORDER CHECK PATIENT RULE EVENT (# entries dependent on site ~300,000) ORDER CHECK RULE (71 entries)

Some Order Checks Currently Used ALLERGY-CONTRAST MEDIA INTERACTION ALLERGY-DRUG INTERACTION AMINOGLYCOSIDE ORDERED BIOCHEM ABNORMALITY FOR CONTRAST MEDIA CLOZAPINE APPROPRIATENESS CRITICAL DRUG INTERACTION CT & MRI PHYSICAL LIMITATIONS DANGEROUS MEDS FOR PT > 64 DISPENSE DRUG NOT SELECTED DUPLICATE DRUG CLASS ORDER DUPLICATE DRUG ORDER DUPLICATE OPIOID MEDICATIONS DUPLICATE ORDER ESTIMATED CREATININE CLEARANCE GLUCOPHAGE-CONTRAST MEDIA GLUCOPHAGE-LAB RESULTS LAB ORDER FREQ RESTRICTIONS MISSING LAB TESTS FOR ANGIOGRAM PROCEDURE NO ALLERGY ASSESSMENT ORDER CHECKING NOT AVAILABLE POLYPHARMACY RECENT BARIUM STUDY RECENT ORAL CHOLECYSTOGRAM RENAL FUNCTIONS OVER AGE 65 SIGNIFICANT DRUG INTERACTION 40

Summary VistA and Ontologies large Hospital Information System multiple sources of content suitable for inclusion and formalization History of Innovative inclusion of technologies Consistent data model and management system Non-unified ontological approach Would benefit from Standard Upper Ontology

Chris Richardson & David Whitten Thank You Questions? Chris Richardson & David Whitten http://www.worldvista.org June 16, 2005