1. U.S. Department of Veterans Affairs VistA
Evolution
Implementation
Case Studies
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2. History of the Veterans Administration
Established in 1930 to provide care for war veterans
Started with 54 hospitals
Today, the VA serves as the largest integrated health care system in the U.S. for Veterans.
Number of patients increased by 29% in 2008
4.5 million in 2001 to 5.5 million in 2008
Currently the VA has:
153 medical centers
909 ambulatory care and outpatient clinics
135 nursing homes
47 rehabilitation treatment programs
232 veterans centers
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3. Group 2: Farabaugh, Jordan, Katzovitz, Odom
Focus on Quality
1960s-70s: VA heavily criticized for its quality of care
Complaints from Vietnam veterans
Unhappy staff
Congressional concerns and complaints
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4. Group 2: Farabaugh, Jordan, Katzovitz, Odom
Computer Technology
Computer technology controlled by the Office of Data Management and Telecommunications (ODM&T) in late 70s
Used large mainframe computers
Largely vendor used software
Poor performance and lack of inoperability
Time consuming development of applications
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Origins of VistA
Medical professionals began to develop their own software in response to ODM&T lack of quality
Known as the Hard Hats
Used MUMPS language
“The database we chose was called MUMPS. It is really an old clunky program, but it proved to be a very good program to hone into an individual patient chart. It drills down information very quickly into one file. However, it is not good at cross referencing the same field in multiple charts. We started with this and did quite well.” (Dr. Lewis Coulson, Jesse Brown VA, Illinois)
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Origins of VistA
Computerized Assisted System Staff (CASS)
Development of the DHCP
Backlash from ODM&T and private-sector
‘Underground Railroad’ movement
DHCP written into law as the information systems program for the VA in 1981
Implemented nationally by 1989
Became known as VistA in 1996
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VistA Today
VistA architecture underpins hundreds of applications
CPRS
VistA imaging
Barcode medication administration
My HealtheVet PHR
…and many more
The VistA architecture is the underlying architecture for hundreds of applications. The gateway application is Computerized Patient Record System, or CPRS. Others that we’ll discuss are VistA Imaging, which allows clinicians to view radiology images for patient, barcode medication administration which seeks to reduce medical errors by making sure the right patient receives the right medication in the right dose at the right time, and MyHealtheVet Personal Health Record, or PHR, that allows veterans to view their medical data via a secure internet connection.
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CPRS
Computerized Patient Record System
GUI EHR: “umbrella program” that integrates a number of clinical applications in a common graphical user interface with a “tabbed chart metaphor”
Solved issues of multiple logins and need to access multiple programs to gather patient information
The CPRS is the graphical user interface that integrates a number of applications into an electronic patient chart
Dr. Louis Coulson, a doctor of internal medicine at the Jesse Brown VA in Chicago, said that before CPRS, physicians had to log into each program they wanted, and look up the patient. If they wanted to view different data in a different program, they would again have to log in and look up the patient. CPRS solves this problem with a single login and integrated view into a patient’s record.
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9. CPRS Workflow Cover Sheet Clinical Intervention Applications
active problems, allergies, current medications, recent laboratory results, vital signs, hospitalization and outpatient clinic history
Cover Sheet
Clinical Intervention Applications
CPOE
narrative notes entry and browsing
Alerting
When the user first logs in, they see a cover sheet with active problems, allergies, current medications, recent laboratory results, vital signs, hospitalization and outpatient clinic history. After the clinician views the cover sheet, he can dig deeper into other applications. These include computerized electronic order entry (CPOE), free text and template-driven narrative notes entry and browsing, laboratory results display, consultation requests, medical image browsing, pharmacy profiling and medication administration documentation, alerting for abnormal results, critical events and services needed in support of clinical guidance.
Lab results
Medication administration
Medical image browsing
Evidence-based clinical guidance
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CPRS Development
Done in concert with clinical process redesign
“If the VHA clinicians had simply computerized existing workflow processes, the significant efficiency improvements that the VHA has demonstrated over the past seven years would not have occurred” (Evans, et al., 2006)
Clinical Applications Coordinator role
It’s important to note that CPRS development was done at the same time as clinical process redesign. They didn’t simply computerize existing work processes, but changed those processes to better fit a technologically enhanced workflow.
Central to this effort was and is the role of the Clinical Applications Coordinator, which Larry is going to elaborate on. CACs are clinical people who have learned enough about technology to serve as liaisons between clinicians and developers to create optimal VistA applications.
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11. Bar Code Medication Administration
Inspired by handheld device used at rental car return
Sue Kinnick, nurse in Topeka, KS, built prototype with developers
Scan patient, nurse, and medication
Alerting if wrong med, dose, patient, or time
Now the standard throughout the US
The way the VA handles medication administration has virtually eliminated errors in this area. A nurse in Topeka, KA, Sue Kinnick, got the idea for barcode administration when she watched an employee at a rental car company check her car back in with a handheld. She worked with developers at her VA facility to come up with a prototype, which was eventually rolled out across the US. At first, the VA had to re-label almost all medications, but today most of them include bar codes.
The process consists of a nurse scanning a patient’s barcoded wristband, then her badge, and then the medication. The systems provides an alert if anything is amiss – wrong medication, dose, patient, or time.
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12. Group 2: Farabaugh, Jordan, Katzovitz, Odom
My HealtheVet is a Personal Health Record designed to optimize health care involvement, participation and awareness for veterans, family members, and clinicians (Vista Information Package, 2006). It includes much more than just personal health information. It gives veterans access to a library of health information, health calculators and self-assessment tools, prescription renewal, wellness reminders, benefits resources, co-payment balance, and VA news and program information.
Kim Nazi, a health informatics specialist in Washington, D.C. told us that guture developments for My HealtheVet also include full access to the medical record, not just portions of it. Also planned are ways to address the challenges of patients receiving “bad news” without appropriate counseling. Patients involved in pilots of the full record report that they are more engaged and empowered in their health care with full electronic access to their health record
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13. Clinical Application Coordinator
Clinically Experienced
Supports clinicians and IT staff in the adoption of technology
Training
Administrate user set-up
Innovate
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14. Clinical Applications Coordinator
CAC Recipe for Success*
Technology 10%
Clinical medicine 10%
Sociology and people 80%
*attributed to Homer Warner
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15. Clinical Applications Coordinator
“Doctors are not very specific, they talk in generalities. The programmers don’t ask enough questions they just start writing code. I had my assistant, Betsy Levin who was one of the first CACs in the country. She was not a programmer, but we taught her how to do some things. She learned how to talk to programmers and speak their language, then get back to the doctors. The CACs I currently work with are a nurse, social worker, speech therapist, and lab tech. All have different backgrounds and can think about patient care. You have to have an intermediary who can do these types of things; they are the most important person in the equation. Don’t train the CACs to do the programming, they just have to talk the language, and be patient with programmers.”
(Dr. Lewis Coulson, Chief Ambulatory of Care & Strategic Planning, Jesse Brown VA)
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16. VistA Challenges & Issues
August 2008 to Dec Medical data errors
Poorly planned capital projects – RSA
Decentralization vs. Centralization
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17. Interoperability: DoD and VA
Wounded Warrior Act of 2007
“develop and implement a joint electronic health record (EHR) for use by the DoD and VA as well as accelerating the exchange of health care information between the two departments.”
September 30, 2009 deadline for interoperability
Did they make it? Depends on who you ask.
The Department of Defense (DoD) and the VA have an overlap in their patient populations, but different approaches to managing health information technology. While the VA houses all patient data in VistA, DoD “uses multiple legacy medical-information systems, all of which are commercial software products that are customized for specific uses. Until recently, those systems could not share information.”
Congress and various federal task forces have been trying to get VA and DoD to interoperate for about a decade, but it was finally signed into law with the Wounded Warrior Act of 2007, which set September 30, 2009 as the deadline for achieving interoperability.
The Interagency Program Office (IPO), the joint DoD/VA office, set criteria that have not been met. However, the criteria set by the Interagency Clinical Informatics Board (ICIB) have been met: making DoD inpatient discharge notes available to the VA, increasing the number of electronic gateways between the two systems, enhancing the sharing of social history, creating the ability to view scanned documents between systems, and making available DoD periodic health assessments and separation physicals to the VA
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QUERI System
Quality Improvement Initiative
Follows a 6 step process
Identify high priority diseases, apply clinical interventions, and document outcomes improvements
The VA’s Quality Improvement Research Initiative, or QUERI system, uses data from CPRS and VistA to improve patient outcomes through 6 steps. It is a process redesign program that uses Total Quality Management (TQM) processes to identify diseases, apply interventions, and document the outcomes improvement from those initiatives.
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First, a disease is identified that is especially burdensome to the veteran population. The system is helpful in this step by providing data about disease burden and helping to identify issues that are good candidates for the process.
Next, best practices are identified for addressing this disease.
Third, existing practice patterns and outcomes from across the VA are collected, and deviation from best practices is identified. Again, the system provides data about these patterns and about outcomes. Sometimes the data are readily available, and sometimes new queries or applications have to be created to get the necessary data.
Next, interventions are identified to promote best practices. This might come from inside or outside the organization. The human-technology interface is really important here, because if it’s not easy for the clinicians to adopt the intervention, it probably won’t be effective.
The best practices that actually improve outcomes are identified, again through system data. Special attention is paid to patient quality of life and patient satisfaction, not just positive clinical outcome.
Hynes, D. M., Perrin, R. A., Rappaport, S., Stevens, J. M., & Demakis, J. G. Informatics Resources to Support Health Care: Quality Improvement in the Veterans Health Administration. Journal of the American Medical Informatics Association. 2(5),
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Jesse Brown VA
VA Hospital in Chicago
188 Beds
7600 Inpatient admission
531,000 Outpatient visits
Budget $235 Million
1,000+ VistA users
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Jesse Brown VA
“The doctors at Jesse Brown cannot imagine working without VistA/CPRS. When we have planned system downtime most users hold as much of the work they need to do until the system is back up.” (Laurie Blum-Eisa Interview 2009)
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Jesse Brown VA
Data stored three locations
Down-time
System features most proud of at Jesse Brown
BCMA
CPRS clinical reminders
Remote data
Imed Consent
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24. Midland Memorial Hospital
VistA implementation in private institution
Small, 371-bed community hospital
Goal to replace systems with a complete EHR
Vista software is available in an open source form for use in private institutions under the Freedom of Information Act.
The OpenVistA implementation at Midland Memorial Hospital, a 371-bed facility in Midland, TX, is a great example of a successful VistA implementation outside of the VA system.
Midland began investigating options for a complete EHR when they received notices that support for several of their legacy systems would no longer be available after Midland’s systems at that time consisted of a hospital information system for financial business purposes and an automated pharmacy system, both with limited interfacing capabilities. Medical records consisted of paper charting.
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25. Midland: Implementation
Chose Medsphere’s OpenVista
Contract in late 2004
Implementation began in early 2005
Software reconfiguration included changes to GUI and enhancements specific to facility needs
Clinical configuration began in summer 2005
Clinical IT team formed
Go-live in June 2006
Paper charts removed February, 2007
Several companies offer versions of VistA for implementation in private institutions. Midland chose to contract with a company by the name of Medsphere this implementation.
A contract was signed in late 2004, …
and implementation began in early A six-month software development began, which involved reconfiguration and enhancements necessary to meet Midland’s unique needs.
Clinical configuration began in This involved the forming of a new clinical IT team that consisted of five RNs lead by a nurse informaticist. This team of clinicians gave valuable input into the design of the new GUI as well as order sets, clinical alerts, and rules.
Go-live took place in June of 2006, starting with a gradual roll-out among areas and proceeding through the facility. Medsphere experts were available to assist Midland staff throughout the implementation process.
By February of 2007, all paper charts were removed from the facility.
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26. Group 2: Farabaugh, Jordan, Katzovitz, Odom
Midland: Cost
Budget was a major factor in selection
Midland had a $6.3 million budget
Average cost for proprietary system in 2003 was between $18-20 million
One of the benefits of the VistA system is its affordability, and this was a major deciding factor for Midland Memorial.
As a small hospital, Midland only had a $6.3 million dollar budget to work with.
However, Midland found that the cost for implementing a proprietary system in 2003 was between $18-20 million.
With Medsphere’s OpenVista, Midland was able to implement a full EHR without exceeding their budget. One cost saver was that extras and add-ons were included in the pre-negotiated contract with Medsphere, whereas proprietary companies would charge extra fees for these services.
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Midland: Success
Staff can now efficiently access entire records
Decrease in medication errors, patient deaths, and infection noted since implementation
Permanent records offer legal protection
HIMSS Stage 6 ranking for electronic health record
The implementation of OpenVista at Midland has been an overwhelming success. Entire medical records can now be retrieved in seconds as opposed to days with the old paper charting system.
The quality of patient care at Midland has measurably increased since implementing OpenVista. Midland has noted a decrease in medication errors and patient deaths. There has also been an 88% decrease in infection rates that has been attributed to built-in system reminders that alert nurses to follow infection-control standards.
An additional benefit of the system is legal protection. The electronic records are permanent, which protects against any changing of the record.
The effectiveness of Midland’s OpenVista system was validated when the facility received designation by the Health Information Management and Systems Society (HIMSS) as a Stage 6 healthcare facility. Stage 6 is the highest ranking yet designated by HIMSS.
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Questions?
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