Health Tech Net July 15, 2005

1. Health Tech NetJuly 15, 2005 Robert M. Kolodner, MD Acting Deputy CIO for Health &Acting Chief Health Informatics Officer Veterans Health Administration Department of Veterans Affairs

2. VistA Supports VHA • ~196,500 Employees • ~15,000 Physicians • 56,000 Nurses • 33,000 Allied Health Professionals PLUS • Affiliations with 107 Academic Health Systems • Additional 25,000 affiliated Physicians • Almost 80,000 trainees each year • ~ 1300 Sites-of-Care • Including 157 medical centers, ~ 850 clinics, long-term care, domiciliaries, home-care programs Source: QTR Exec Summary Mar 2005 Health Tech Net

3. VistA’s Cost • VA runs 128 VistA systems these sites • Down from 172 VistA systems 10 years ago • ~180,000 PCs and thin clients • For FY2004: • Cost per enrollee • $78 / enrollee • Average cost per hospital (n=158) • $3.6 million • Delivers a complete hospital information system, electronic health record, imaging, BCMA • Hardware, software, maintenance, upgrades, staffing Health Tech Net

4. And VistA Is Actively Used... Some National VistA Statistics (Total / Daily) • Documents (Progress Notes, Discharge Summaries, Reports) • 698,000,000…….. +567,000 each workday • Orders • 1.4 Billion……. ... +931,000 each workday • Images • 338,000,000……… +534,000 each workday • Vital Sign Measurements • 863,000,000……… +676,000 each workday • Medications Administeredwith the Bar Code Medication Administration (BCMA) system • 670,000,000……… +616,000 each workday Statistics as of June 2005 Health Tech Net

5. . . . Because healthcare (in the U.S.) is a trillion-dollar cottage industry! ” Medical Computing Status “ . . . Given the huge increase in personal computer and Internet use, as well as the dramatic changes in other industries, most consumers assume that healthcare is highly electronic and computerized. The reality, however, is that 90 percentof the businessof healthcare remains paper-based. Why? ” Rx 2000 Institute http://www.rx2000.org/KnowledgeCenter/hipaa/elearning/QC_govt.htm Health Tech Net

6. Except in VA ! Every VA Medical Center has Electronic Health Records ! Health Tech Net

7. Praise for VistA… “VHA’s integrated health information system, including its framework for using performance measures to improve quality, is considered one of the best in the nation.” Institute of Medicine (IOM) Report, “Leadership by Example: Coordinating Government Roles in Improving Health Care Quality (2002)” Health Tech Net

8. (Still More) Quotes About VistA . . . “…nowhere is the VA outrunning the private healthcare sector by a wider margin than in the adoption of clinical information technology.” Modern Physician, August 1, 2003 “The Electronic Health Record in the Department of Veterans Affairs is the best in the United States, absolutely the best at large scale, and probably the best in the world.” John Glaser, Ph.D., October 2003Vice President & CIOPartners (Harvard) HealthCare System Health Tech Net

9. However This is NOT about technology… It is about RESULTS: • Improved Health Care Quality • Improved Health Outcomes Health Tech Net

10. And in January 2005… Health Tech Net

11. Performance MeasurementSetting the U.S. Benchmark for 18 Comparable Indicators Health Tech Net

12. Highest Quality of Care For Patients in VA Measured Broadly “Patients from the VHA received higher-quality care according to a broad measure. Differences were greatest in areas where the VHA has established performance measures and actively monitors performance.” Annals of Internal Medicine, December 21, 2004 Health Tech Net

13. Agenda Current VistA HealtheVet-VistA HealthePeople-VistA Health Tech Net

14. Past and Present Health Tech Net

15. Success In Supporting Health Care Delivery For Millions Of Veterans • VistA is a success • Built by “fire” of VHA collaboration • Publicly owned by VA; plan to remain so for the next generation system • Strong interest by public/private in using VistA • National software w/ local flexibility/innovation: • Began as a system in each of the 172 major VA facilities • Innovation developed locally & enterprise wide • Standard packages distributed enterprise wide, e.g. latest version of CPRS Health Tech Net

16. VistA Features • Renamed “DHCP” to “VistA” w/ the launch of CPRS • Veterans Health Information Systems and Technology Architecture • 100+ separate business packages that support day-to-day activities of healthcare operations, including • Provider systems • Registration/enrollment/eligibility • Management and financial systems Health Tech Net

17. In 1996, VA launched the “Computerized Patient Record System” -- CPRS-- a comprehensive, integrated Electronic Health Record (EHR) Health Tech Net

18. VistA’s Contribution to VA Creating a Culture of Quality: The Remarkable Transformation of the Department of Veterans Affairs Health Care System “What was largely an inpatient, subspecialty-based system became a “full-service,” integrated delivery system committed to a new model of health promotion, disease prevention, and coordination of care. … The “culture of quality” depended on the successful implementation of several innovations: a uniform data collection system facilitated by nationwide implementation of an electronic medical record system, systematic application of quality standards, and externally monitored local area networks to monitor quality.” Annals of Internal Medicine, Editorial, August 17, 2004 Health Tech Net

19. Electronic Health Records &Computerized Provider Order Entry • Computerized Provider Order Entry (CPOE) is one of the Leapfrog Group’s “Top 3 Safety Strategies” • Outside of VA, CPOE < 8% nationally • < 30% among Academic Medical Centers • Nationally, 94% of all VA prescriptions are entered directly by providers • Ultimate Goal: 100% • VA is the Benchmark for CPOE Health Tech Net

20. Clinical Reminders Links Reminder • Contemporary Expression of Practice Guidelines • Time & Context Sensitive • Reduce Negative Variation • Create Standard Data • Acquire health data beyond care delivered in VA With the Action With Documentation Health Tech Net

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25. Morphing from VistA to HealtheVet-VistA • What has happened in the past year? • Data Standardizationprogressing in first few domains • Health Data Repository - HDR (version 1) - ready for initial deployment • Launching pilots to implement Regional Data Processing Centersto replace facility-based system distribution • Last CPRS (in Delphi) – Version 26 – due out in October • CPRS-R getting ready for testing • Administrative Data Repository (ADR) concept developed and being pursued • Investing in Common Services and initial Rehosting • Pharmacy re-engineering restructured to deliver in ~2008 • Laboratory re-engineering getting underway this year • Scheduling alpha test delayed until Fall 2005 • My HealtheVet steadily adding new capabilities 142 Latest CPRS GUI Enhancements Health Tech Net

26. The Future Next Generation VistA…….. Health Tech Net

27. VistA - Why change? • Not lose functionality we have • Strengthen VistA • Move to person & data focus • Move to standardized, fully sharable health data • Approximately 30% of veterans receive care at two or more VHA facilities. • An estimated 40% of veterans we treat receive care outside of VHA • Increase system availability and reliability • Increase flexibility to respond to future health needs • Lower cost of maintenance • Modernize & replace older systems • Ensure documentation on application programs • Move to modern technologies Health Tech Net

28. Operational (Clinical) Drivers for Change • Support our future health system • Maximize • Health/wellness/abilities • Satisfaction • Quality • Accessibility/portability of care • Affordability to taxpayer and Veteran • Patient safety (defects/errors to zero) • Security and privacy • Minimize (for the Veteran) • Time between disability/illness & maximized function/health (time to zero) • Inconvenience (inconvenience to zero) Health Tech Net

29. What is HealtheVet-VistA? • HealtheVet-VistA • is the REPLACEMENT of the existing VistA system by rehosting, enhancing, and/or reengineering current health information applications to process on a new technology platform • Hardware and services • will be redundant (a good thing) and “COOP’ed” [Continuity of Operations] • Modernization effort includes • Systems Platform • Software Design • Development Methodology Health Tech Net

30. HealtheVet Strategy Overview • Built on VistA /CPRS foundation • Minimizes change for the health care providers • Built collaboratively • by VHA field/CO leadership & staff and with the Department • Existing components of the current VistA system will be retired incrementally • …as HealtheVet-VistA is deployed in stages • Will eventually replace all VistA software • Migratory/evolutionary process as risk mitigation • “Morphing” from VistA to HealtheVet-VistA • Remains publicly owned Health Tech Net

31. Health Data Repository (HDR) – A Step Towards HealtheVet-VistA • The “data” layer • A central repository of person-centered clinical & health information • for use by clinicians and other personnel in support of patient-centric care  • supports clinical decision-making for better quality, safer patient care, independent of where the patient information was first entered • Health Data Repository (HDR) • Domain-by-domain filling of the national HDR as local VistA data is “cleaned” to align with new standards • Start with Allergies, Outpatient Pharmacy, Vital Signs, Laboratory Results by the end of July 2005 • Standardized (and computable) data from all VHA sites VHA will make a “Quantum Leap” as VHA-wide database integration becomes operational Health Tech Net

32. This is an actual patient who has been seen in 36 different VA medical centers in the past 10 years. Allergy reactants were recorded differently in Cheyenne and St. Louis (and probably in many other sites). For example, Vistaril and Hydroxyzine are the same drug. Decision support will be strengthened when allergy reactants are standardized. Health Tech Net

33. HDR – The Benefits • Health Data Repository (HDR) • Becomes the source for non-local data once the domain is “turned on” • Feeds a clinical data warehouse for further analyses & research (with appropriate privacy controls) • Fall 2005 - Drug/Allergy and Drug/Drug Interactions across VHA • Increases patient safety across VHA • Will exchange pharmacy & allergy information with DoD for patients receiving health care in both systems • Provides real-time interaction detection for both VA & DoD data Health Tech Net

34. HDR – Some Content • Health Data Repository (HDR) – First 12 of 34 Domains • Demographics • Pharmacy • Allergies/Adverse Reactions • Vitals • Laboratory • Problem List • Text Documents (Text Integration Utilities / Notes) • Orders • Encounters • Health Factors (support the clinical reminders capabilities) • Radiology • Immunizations Health Tech Net

35. Current State Facility-centric Data is not standardized from site to site, therefore it is not computable Automated Clinical Decision Support uses data only from the local VistA system (1 of 128) Future State Patient-centric (Veteran-centric) Standardization of data becomes the foundation for decision support functionality Automated Clinical Decision Support is available in real time across allsites of care HDR – How Is It Different Than Current State? Health Tech Net

36. Personal Health Records Health Tech Net

37. Principles: My HealtheVet (Phase 1) Veterans Day 2003 • The veteran "owns" his/her My HealtheVet Personal Health Record • The VistA Computerized Patient Record System (CPRS) is the authoritative VA medical record • The veteran can request that a copy of his/her VistA record be electronically extracted and sent to the My HealtheVet system www.myhealth.va.gov Health Tech Net

38. Three Iterative Implementation Phases: PHASE 1 November 2003 PHASE 2 November 2004 – Summer 2005 PHASE 3 Fall/Winter 2005-2006 Content Contributors Electronic Health Record Engagement Prescription Refill Showcasing Parallel Tracks Self-Entered Information Health Populations Clinician / Patient Messaging View Appointments Health Tools Moderated Discussion View Co-Pay Balance On-Line Education / Training VA Services Self-Entered Metrics Personalization My HealtheVet My HealtheVet is a new ehealth portal where veterans, family, and clinicians may come together to optimize veterans’ health care. What’s Coming…… Health Tech Net

39. “To be” (VA & Beyond) Health Tech Net

40. VA, DoD, IHS individual/joint adoption Convergence Consolidated Health Informatics (CHI) HealthePeople(Fed) • National -- Public/Private • Individual (e.g. Kaiser Permanente) • Joint (NHII, Connect. Health, eHI, HIMSS, NCVHS, SDOs, etc.) HealthePeople DoD CHCS II & TRICARE Online VA HealtheVet/People-VistA & My HealtheVet IHS (upgraded RPMS) HealthePeople(Fed) • National – Public/Private • Individual (health providers/payers/regulators, private sector vendors) • Joint (NHII, CMS/VA, Connect. Health, etc.) Convergence HealthePeople Progress Toward US “Virtual Health Systems” US Person-Centered “Virtual Health System” National Standards Info Exchange / Sharing High Performance Info Systems Personal Health Systems/ Records Health Information Systems (EHR, PHS/R, Exchange) Standards 2001 2010

41. Charge for VA’s EHR to Meet Needs Beyond VA “Within 90 days, the Secretary of Veterans Affairs and the Secretary of Defense shall jointly report on the approaches the Departments could take to work more actively with the private sector to make their health information systems available as an affordable option for providers in rural and medically underserved communities.” President Bush’s Executive Order 13335 – April 27, 2004 Health Tech Net

42. VistA Is Being Enhanced For Use By Non-VA Providers • VA is partnering with Centers for Medicare and Medicaid Services (CMS) to ensure availability of high quality, standardized, interoperable and affordable electronic • Hope to stimulate broader adoption & effective use of EHRs • VistA - Office EHR • A version of VistA configured to be affordable and to meet the needs for use in community health clinics and office based practices in rural and underserved areas • Goal to make an EHR available to 1-8 physician practice • Doctors Office Quality Information Technology (DOQ-IT) connectivity to VistA Office EHR • Enhancements will be incorporated into core VistA & will reflect changes made in core VistA – only 1 version of VistA • Expected release – August 2005 • More information athttp://www.cms.hhs.gov/quality/pfqi.asp Health Tech Net

43. Current VistA Is Already Used Elsewhere • Currently used by several non-VA organizations (partial list) • Indian Health Service (modified version of VistA) • Egyptian National Cancer Institute • American Samoa • DC Department of Health • Oklahoma State Dept. of Veterans Affairs (State Veterans Homes) • Other healthcare organizations are exploring the use of VistA Health Tech Net