1. VA Design Patterns Briefing and VistA Evolution Update
November 17, 2014
Dr. Aaron Drew
Senior Enterprise Solutions Architect
Office of Information and Technology (OI&T)
U.S. Department of Veterans Affairs (VA)

2. VA Design Patterns Briefing and VistA Evolution Update Overview
Two topics
VA Design Patterns
VistA Evolution Update
In the interest of time, please direct all questions to:
Answers will be provided to participants following this meeting

3. Open Source Memo and Survey
Open source Memo (signed by Mr. Stephen Warren on 4 Nov 2014)
Establishes requirements for VA to thoroughly evaluate Open Source Software (OSS) solutions when acquiring software and to consider the use of OSS development practices within VA.
A white paper on impact of VA design patterns on open source community was also requested – the core of this paper was a survey of the open source community.
Methodology:
8 multiple choice questions with a comments box and 2 short answer questions
Sent to approximately 2,600 members of the OSEHRA mail group; 18 surveys received
Based on the survey results:
The open source community understands why the VA is using design patterns, however, there are questions about the implementation of these design patterns.

4. The community understands why VA is using design patterns...

5. But there is some skepticism as to their value...

6. Enabling and Empowering Open Source Innovation
Potential Solution 1: Sandbox environment
Establish an open source sandbox that will provide implementations of SOA services for testing.
Potential Solution 2: Crowd-source capabilities
Couple open-source innovation with VA’s deep institutional VistA knowledge base by promoting collaborative development.
Potential Solution 3: Engagement between VA/Open Source Community
Continue to engage with the open source community through white papers, town halls, and regular briefings.

7. VA Design Patterns Briefing and VistA Evolution Update Overview
Please direct all questions to:

8. VistA Evolution Program Clinical Overview
Dr. Walter Paul Nichol
Deputy Chief Informatics Officer
Veterans Health Administration (VHA)

9. VA Blueprint for Excellence
PERFORMANCE  INNOVATION  SERVICE  ACCOUNTABILITY 1
Anticipate and meet the unique health care needs of enrolled Veterans 2
Deliver high quality, Veteran-centered care rivaling the private sector 3
Leverage IT, analytics, and delivery models to optimize health 9 4
Develop a Veterans First culture, and inspire employees to highest performance
9/8/2014 5
Foster continuous learning, responsible risk taking, and personal accountability 6
Advance personalized, proactive, patient-driven care 7
Lead the nation in research and treatment of service related conditions 8
Become a model Integrated Health Services Network 9
Operate with integrity, transparency and accountability
9/8/2014 10
Modernize health records (HR), procurement, payment, IT and infrastructure to be agile and efficient

10. PERFORMANCE  INNOVATION  SERVICE  ACCOUNTABILITY
VistA Evolution Delivers and Maintains a VistA-based product that Facilitates High-quality Healthcare, Benefits and Services to our Service Members and Veterans.
PERFORMANCE  INNOVATION  SERVICE  ACCOUNTABILITY 1 2 3 4 5 6 7 8 9 10
VistA Evolution satisfies Interoperability, EHR Certification, and Care Coordination requirements
VistA Evolution improves the lives of Veterans
NDAA 2014
VistA provides VA with a solid EHR foundation. VistA 4 is about improving our foundation so we can build a modular HIT product to more rapidly and specifically meet the needs of patients and those providing services to them

11. Our FY15 priority is to develop and achieve ONC 2014 EHR Certification for the enterprise Electronic Health Management Platform (eHMP)
ONC 2014
EHR Certification
Number One
Priority for
VistA Evolution in FY15
Strategic Alignment 1 2 3 4 5 6 7 8 9 10
Prioritize VistA Evolution and Interoperability work, aligned with a compelling Strategy to benefit Veterans

12. Why ONC Certification is a Top Priority
Direct value to Veterans (a few examples)
Improves interoperability of key health information with non-VA providers
Allows Veterans to fill VA-ordered prescriptions at retail pharmacies
Automated scorecards to monitor and improve performance on clinical care, such as screening for smoking and colorectal cancer
Improved capability to reconcile medication list data from multiple sources
New capability to reconcile problem list and medication allergy list data from multiple sources
Improved clinical decision support including usage of HL7 InfoButton
technology
More secure online access to MyHealtheVet 1 2 3 4 6 8 1 2 6 8 1 2 3 4 5 7 9 6 1 2 6 8 1 2 6 8 1 2 3 4 5 7 9 6 1 2 3 4 5 9 6 8
Direct value to part-time VA doctors in the CMS incentive program
Providers must have at least 50% of their total encounters occurring at facilities with a certified EHR in order to be eligible for CMS incentives
Providers attesting to MU will need to be less than 50% at VA until we have a certified EHR
Allows VA to maintain credibility as a leader in Health IT
All Major EHR products in the commercial market are ONC Certified today
Catalyst to create a solid foundation for an open standard/open architecture EHR platform

13. VistA Evolution Triple Aim: Team-Based, Veteran-Centric, Quality-Driven1 2 3 4 5 6 7 8 9 10
Veteran-Centric
Quality -Driven
Team-Based

14. VistA Evolution Program
User experience that makes it easier and more pleasurable to get work done.
Faster response
Shorter time to acquire needed information
Enhanced clinical decision support
Improved speed of documentation.
Studies show EHRs increase work by 75 to 90 minutes a day.
Coordinated care:
Patient-centric, team-based, and quality driven healthcare
Veteran-driven goals drive the plan
Task-based communication (including orders) improves speed and clarity of communication while automatically tracking into care plan (may save 30 minutes a day)
Lays foundation for many new workflows to support specialty care areas such as women's health and mental health, as well as population health, etc.

15. VistA Evolution Program
Enhanced DoD Interoperability: Architectural work underway to improve performance and reduce maintenance for components supporting DoD interoperability.
Advanced Indexing and Enablement of Clinical Data Enrichment: VistA Exchange leverages the eVPR cache to create a universal index for search. This allows for the addition of external clinical enrichment features (e.g., natural language processing, tagging, and annotations).
Web-Based Computerized Patient Record System (CPRS): A web-based alternative to CPRS is being developed. First release of the this new User Interface (UI) will be December This UI is leveraging designs, functionality, and capabilities of the hi2 Health Management Platform (HMP) UI.
Decoupling of Ancillaries from Core Clinical Functionality Through Open Standards: An open, standards- based services for Orders Management and Order Selection will be created. This will allow orders to be managed as enterprise activities, and will decouple the generation of the clinical record from ancillary fulfillment, thus facilitating the selection and integration for Commercial-Off-the-Shelf (COTS) ancillary products such as Laboratory and Pharmacy (the ancillary product acquisitions are outside of the scope of eHMP project).
Other Evolutionary Generation 3 EHR Capabilities: This would include services for Clinical Workflow and Activity Management, Decision Support, and Concept Relationship.

16. VistA Evolution Program Update

17. VistA Evolution Program
The VistA Evolution Program will enhance VistA’s core architecture to achieve interoperability with DoD.
Further work will augment VistA’s clinical capabilities to support a patient-centric, team-based healthcare delivery model. The Program’s end product, VistA 4, will deliver cross-agency interoperability, a robust health IT architecture to enable future innovation, and cutting-edge clinical capabilities, allowing VistA to serve as a cornerstone for the delivery of care and benefits to Veterans, Service members, and their dependents.

18. VistA Evolution Program
Feature Set 1 (Delivered September 30, 2014)
Feature Set 2 (To Be Delivered By September 30, 2015)
Interoperability (through JLV)
VistA Standardization, Phase 1
Vista Immunization Enhancements (VIMM, 1.0)
Laboratory
Graphical User Interface (GUI) Tools
VistA 4 Application Programming Interface (API), Initial Release
ONC 2014 EHR Certification
VistA Scheduling Enhancements
VistA API Exposure, 2.0
iMed Consent Web Migration
Enhancements to Pharmacy (MOCHA, PECS, PPS-N, PPS-L, SUMPM)
VistA Standardization, Phase 2
Feature Set 3 (To Be Delivered By December 31, 2016)
Feature Set 4
(To Be Delivered By September 30, 2018)
Interoperable EHR
Broad eHMP Deployment
Enhancements to Pharmacy (In-bound e-Prescribing)
VistA Standardization, Phase 3
VistA Service Assembler
VistA Immunization Enhancements (VIMM, 2.0)
Medical Appoint Scheduling System (MASS) – broad deployment
Enterprise-wide eHMP Deployment
Veteran’s Authorization and Preferences (VAP)
Women’s Health
Enhancements to Ancillary Systems (Radiology, Laboratory)
FileMan Modernization

19. VistA Evolution Program Update: Select Projects
JLV/eHMP/VistA Exchange
Mr. Keith Michael, eHMP Lead Architect/Product Manager
Ms. Betsy Green , eHMP Project Manager
FileMan Standardization and Modernization
Mr. Russell Holt, FileMan Portfolio Manager
Enterprise Messaging Infrastructure (eMI)
Dr. Patrick Pearcy, Director, Veteran Facing Applications and Service Integration

20. VistA Evolution Program Update: JLV/eHMP/VistA Exchange
Mr. Keith Michael, eHMP Lead Architect/Product Manager
Ms. Betsy Green , eHMP Project Manager

21. Joint Legacy Viewer (JLV)
JLV is the newest health record viewer available to users in both DoD and VA to meet increasing needs for seamless interoperability of standards-based health data supporting high quality care for our nations’ Veterans and Service members. JLV is the only application providing an integrated, chronological view of electronic health record information from all VA and DoD facilities at which a patient has received care, in a user-configurable display.  
JLV is a waypoint on the path to the state-of-the-art, interoperable, standards based VistA 4 enterprise Health Management Platform (eHMP)

22. Enterprise Health Management Platform (eHMP) Overview
The eHMP project is a multi-year effort to evolve a modern, service oriented enterprise health application platform. It will provide ‘native federation’ of a complete enterprise Virtual Patient Record (eVPR), including information model binding, terminology normalization, knowledge enrichment, and search indexing for all available longitudinal patient record data aggregated from VA, DoD, and exchange partner sources.
eHMP is the name of the overarching system encompassing both the front end application and middle tier components called eHMP Services
eHMP Services is the name for the middle tier components that include
VistA Exchange (Virtualization of Patient Record)
Clinical Decision Support
Context Persistence
Orders Selection Service
Orders Management Service
Data Annotation Service
Clinical Workflow
Concept Relationship Service
Documentation and Text Search Service
Business Rules Management System

23. Enterprise Health Management Platform (eHMP) Overview
Will eventually replace the Computerized Patient Record System (CPRS) as VA’s primary point of care application.
Will show information in a single view, which will allow clinicians to use comprehensive patient data and images more easily, instead of a siloed approach which can sometimes hinder the exchange of information. This foundational delivery will also integrate several functionalities into the DoD/VA interoperability infrastructure to support the VistA Evolution Program’s interoperability commitment. These additions will give clinicians simplified access to Veterans’ complete patient history from both DoD and VA shown in a single reliable and secure interface.
Consists of a middle tier that enables enhanced clinical information exchange through various components that find, standardize, and interpret many sets of information, to include demographics, lab and immunization results, visit management, problem/medication list, and more.

24. Software Development Kit (SDK) Technical Details
Components
Application Development Kit (ADK): Client-side
JavaScript : Language
Backbone.js : Library to develop SPA
Marionette : Framework for backbone.js applications
Bootstrap : Libraries for front-end development
Resource Development Kit (RDK): Server-side
Express.js: Web Application Framework
Single Page Application (SPA)
HTML/JavaScript/CSS returned as “static assets” from web server
Logic performed in client instead of server
Fluid and more responsive
No reloading and re-rending
JSON creates separation between presentation and application logic

25. Application Development Kit (ADK)
Applet
Single unit of visual functionality
Screen
Defined collection of applets
Layout
Abstract arrangement of applets
Application
Collection of screens
Majority of web developers working within eHMP UI will spend their time developing applets.

26. Resource Development Kit (RDK)
Single web service
(e.g.
Resource Family
Collection of resources
(e.g. class)
Resource Server
Deployable unit, includes a set of resource families and specific configuration
(e.g. war file)
The approach to resource servers follow “microservice”
Allows for discrete instances to be independently deployed, optimized, and load balanced

27. Working Draft, Pre-Decisional, Deliberative Document – Internal VA Use Only
Open Source:
InterSystems Caché
Apache Lucene Solr
Drools (Future)
Apache Tomcat
Express.js
Node.js
HL7 FHIR Web Services
eHMP SDK
XACML 3.0

28. Cover Sheet Mock-Up
Add new page design

29. VistA Evolution Program Update: FileMan Modernization & Standardization
Mr. Russell Holt, FileMan Portfolio Manager

30. VistA FileMan Modernization & Standardization
Key features
Standardization of VistA applications and their corresponding database, including federating application data to create an enterprise-wide view of patient data.
Population and cohort queries for applications that are fully converted to use FileMan Enterprise.
Powerful interfacing and integration capability of any VistA application to data source, application, or external system.
Standardized, enterprise Application Programmable Interfaces (APIs) to VistA applications. These allow interfacing of external applications to all VistA systems through one enterprise API.
Interface Modern Internet Database capabilities, including secure web services, web interfaces, and web data management capabilities.
Standardize unified method of access for all VistA data through FileMan programmatic interfaces.
Ensure FileMan data storage and access supports universal time zones (UTC) (FileMan will be able to store by implementing UTC offset)
Enterprise-wide secure FileMan access expand/enhance single character use

31. VistA FileMan Architecture

32. FileMan “As-Is” Architecture
WebLogic
VistALink

33. FileMan “To-Be” Architecture
Working Draft, Pre-Decisional, Deliberative Document – Internal VA Use Only
Enterprise VistA
Data
base
(1)
Enterprise
Apps
FileMan
API’s
Database
(126)

34. VistA Evolution Program Update: Enterprise Messaging Infrastructure (eMI)
Dr. Patrick Pearcy
Director, Veteran Facing Applications and Service Integration

35. Enterprise Messaging Infrastructure (eMI)
eMI is the sustainment phase of the Service-Oriented Architecture (SOA) Suite project.
Provides the ‘transport’ for the messages between both DoD/VA and supports the associated information management systems in a standards-based, secure and reliable manner.
Simplifies the integration of new capabilities, web services, and other technologies.
eMI will continue to facilitate the delivery and use of reusable services in support of VA and other health partners, as dictated by the National Defense Authorization Act (NDAA).
eMI has been in place since August 2014.

36. Enterprise Messaging Infrastructure (eMI) Architecture

37. VistA Evolution Update
Please direct all questions to: