FAQ about the VHA Health Information Technology program in FY06

1. FAQ about the VHA Health Information Technology program in FY06 IHS Tech Conference Albuquerque, NM June 20-23, 2006 Clayton Curtis MD PhD VHA-IHS Interagency Liaison VHA Office of Information

2. Why should I care what’s happening in VHA? Clayton Curtis MD PhD

3. VHA and IHS have a history… • VHA and IHS have a 20-year partnership in large-scale clinical computing; VHA’s technology was adopted in 1984, and the first MOU was negotiated in 1986 • VHA and IHS have large Federal “health care chain” deployments of a comprehensive clinical information system • VHA and IHS are both influenced by Federal initiatives including FHA and ONCHIT Clayton Curtis MD PhD

4. But time has marched on… • RPMS began as an offshoot of DHCP in 1984 • VHA and IHS have both undergone major organizational change (VHA: integrated service delivery networks; IHS: tribal compacting and program expansion) • VHA and IHS have slowly diverged due to different priorities and interests; that has impacted IHS ability to absorb new releases of VHA packages and leverage VHA investment Clayton Curtis MD PhD

5. And here we are today… • IHS has identified migration to electronic records and closer approximation to core VistA packages as major initiatives • IHS has migrated to a component-based GUI framework for electronic records (ViewCentric / EHR – 26 live sites) • VHA and IHS staff are working to get EHR pilot sites (and, eventually) all sites in synch with current releases of core VHA packages • VHA is undertaking a major change in the technology base for VistA, and re-engineering major applications (HealtheVet VistA) Clayton Curtis MD PhD

6. Soooo… Back to FY06 Clayton Curtis MD PhD

7. FY06: The Year of Extraordinary Changes • New Congressional oversight committee • New VHA CIO, departure of VA CIO • Budget cuts • Congressional requirement for reorganization of VA IT • Congressional “hold” on funds for HealtheVet program pending reorganization Clayton Curtis MD PhD

8. What happened to the VHA IT budget? Clayton Curtis MD PhD

9. Non-pay funding requests of $395M (“dream number”), limitation to level of OMB submissions of $323M, funding to a lower level of $135M Cuts translated into a strategic pause that is allowing development of stronger programmatic and engineering underpinnings for HeV Congressionally mandated split between IT and non-IT funds, no ability to convert without Congressional approval Delay in HeV development (including CPRS and other clinical projects) related to loss of funding for contract development resources Clayton Curtis MD PhD

10. HealtheVet Budget Reductions (FY 06) Dev Budget Reduction (Overview) Development Reductions (Actuals) Ops & Maint. Reductions (Actuals) FY06 Ranking Guidance from Leadership: • Sustaining Current Baseline VistA Application Ops • Patient Safety • Critical SW Improvement For Identified Medical Issues • Clinical Improvements For Accreditation And Efficient Care Delivery • DOD Seamless Transition • Presidential And Secretary's Priorities/Congressional Mandates • Efficient Financial Processing Clayton Curtis MD PhD

11. What’s this about a VA IT reorganization? Clayton Curtis MD PhD

12. Congressionally-mandated reorganization of IT at the Department level, with budget control and accountability vested in the VA CIO Distinction between “operations” and “development” all “operations” staff detailed to VA IT organization in preparation for permanent reassignment “development” staff and activities remaining with Administrations New structure for overall program management Shift to project implementation drawing on competency-based development organization Clayton Curtis MD PhD

13. HealtheVet (HeV) Systems Development Organization HPMO has overall responsibility for Systems-of-Systems integration and total program performance with oversight responsibility for Program Managers executing on-performance, on-cost, and on-schedule! Clayton Curtis MD PhD

14. Selected Portfolio Health Program w/ Assigned Projects (Sample) PROGRAM OFFICE for Health Provider Systems Program Manager Functions Drawn From The Organization: Business / Financial Management Specialists HR Specialists Project Managers Program/Projects Analysts ASSIGNED PROJECTS (Incomplete) VistA Imaging Clinical Procedures Pharmacy Computerized Patient Record Systems (CPRS) Laboratory Radiology Scheduling Health Data Repository (HDR) Nursing RESOURCE PROVIDERS Systems, Network & Software Engineering Development Competencies Security Management Systems Engineering Network Engineering Clayton Curtis MD PhD Software Engineering Database Management

15. HealtheVet FY 06 Project Re-Definition Clayton Curtis MD PhD

16. What’s the story on the VA data theft that’s been in the news? Clayton Curtis MD PhD

17. Laptop stolen from home of employee with VA (not VHA) Office of Policy and Planning. Laptop contained demographic information on a large number of veterans and active duty personnel (due to DoD notification of status to VHA). No clinical data involved. Remediation measures include accelerated privacy / security training, letter from Secretary to veterans; recall of laptops and encryption of hard drive anticipated. Employee and supervisor terminated. Cost to VHA for VA-level problem is significant; some project funds being diverted. PR cost – public and Congress – is perhaps the worst outcome. Inaccurate and misleading posts on the internet are harmful. Clayton Curtis MD PhD

18. What’s up with CPRS development? Clayton Curtis MD PhD

19. Decision made to skip “rehost” phase and move on with re-engineering Alternatives to HeV Desktop framework being evaluated Virtual Patient Record developed to simplify access to data in GUI client Consolidating and synthesizing information from the problem list meeting, the earlier document meetings, and PCS retreats as models are created for CPRS-R. Focusing on problem oriented charting and beginning some straw man mockups. Writing "spikes" - slices through the layers of technology to test out architectural assumptions and to gather evidence to help identify acceptable technical approaches. This has resulted in significant simplification over what was planned for re-host. Clayton Curtis MD PhD

20. Is there anything tangible going on with HeV? Clayton Curtis MD PhD

21. HealtheVet-VistA Projects – FY06 Current Architecture Data Standardization • - The establishment of data standards across all VHA sites to ensure system interoperability and exchange of compatible information with other Federal and private health care providers. Reengineering - Reengineering is the movement of the existing M-based applications into the HealtheVet-VistA (HVV) architecture and data structures. This work is the heart of the move to HVV. There are approximately 65 existing VistA applications that must be reengineered. • Problem List • Clinical Documents • Immunizations • Radiology • Orders • Encounters • Adverse Reactions • Lab LDSI Support • Lab – Phase I & II • Pharmacy Phase II • Field Support & • Standard Maint. • Project Mgmt. & ODC • Clinical Procedures • App Dev. Process Security • CPRS-R • HeV Foundations • * Reengineering effort refers to FY06 • only. Numerous other applications • will be rehosted in the future. Future Architecture Common Services • - A “service oriented” architecture – similar software functions in different applications are isolated and streamlined so they can be coded once and reused many times. • Person Service- Demographics • Person Service-Identity Management • Delivery Service • Standard Data Service • Administrative Data Repository (ADR) • ADR Data Migration • National Provider Identifier Projects, on completion, provide incremental & immediate benefits to HealtheVet current and future capability Clayton Curtis MD PhD

22. HEV: 100-day Projects • Pilots for agile development in new technology • Prototype for HeV development practices • IHS involvement planned Clayton Curtis MD PhD

23. Introducing Agile Development to VHA • Agile Projects for VHA: • Fixed time, resources, e.g., 25 staff, 6 months. • Working software in short cycles, e.g. 3 weeks. • On-going coordination of business and technical. • Disciplined planning, performance, and reporting. • Business value delivered. • Compliance with and contribution to new • HealtheVet enterprise architecture. • Contribution to repeatable processes. Agile projects support business processes by delivering software in short cycles. • Initiate Agile Development • Demonstration projects to establish viral growth. • Candidate projects from VHA business owners, selected for low cost/risk and high benefit, for business and technical value. • Subsequent projects extend business coverage, architecture and process. Clayton Curtis MD PhD

24. Initial Agile Demonstration Projects • Emergency Department • Summary: provides physicians and nurses with patient status for delivery of care, and provides department management with oversight. • Status: Well-defined need; active user community; current facility-based pilots provide project definition. • Business Value: improves quality of care, resource use, and performance measurement. • Technical Value: establishes workflow, business rules, services for legacy access, UI standards, 508 compliance. • Process Value: establishes responsive engagement of OI with business owners, sponsors and users for a project with demonstrated scope. • Patient Handoff • Summary: supports planning, performance and reporting of handoffs of patients, e.g. between shifts, staff, departments, units, and in/out of VHA. • Status: established need and NCPS-based user community. • Business Value: improves patient safety under JCAHO standard. • Technical Value: extends use of workflow and business rules; establishes standards for security; establishes services for COTS integration. • Process Value: extends OI/business process engagement to project definition. Clayton Curtis MD PhD

25. HEV: Progress on HDR • Allergies, outpatient pharmacy, vitals (1B) now in HDR • Lab is the next domain to be extracted; target is 10/06 • HDR Data Warehouse now contains outpatient pharmacy and vitals. Allergies is the next domain to populate the data warehouse, followed by Lab at the end of ‘06 • Clinical Delivery Service for national HDR II now working on Iteration 6. This iteration will help create a model for the CDS product that is sufficiently extensible to meet the majority of future CDS functional requirements. Clayton Curtis MD PhD

26. Has there been any progress in IHS use of VistA Imaging? Clayton Curtis MD PhD

27. Project agreement signed May, 2006 Sets ground rules for use in IHS Makes IHS a distributor of VistA Imaging as a medical device Provides funding for VHA support of alpha implementations in FY06 Initial VistA Imaging test site implemented GIMC planning VistA RAD implementation; informational meeting held at PIMC (BTW: DoD just announced it is adopting VistA Imaging for AHLTA) Clayton Curtis MD PhD

28. What about Bar Code Medication Administration? Clayton Curtis MD PhD

29. IHS is developing a patch for BCMA that will allow use of other than SSN for patient identifier Parameterizes code for use outside VHA Supports Health Record Number as identifier Supports alternative header text in displays and reports Software Requirements Specification and System Design Document developed and reviewed by VHA Development and testing should begin soon Clayton Curtis MD PhD

30. How are IHS and VHA developer communities engaging? Clayton Curtis MD PhD

31. Emails, calls on specific topics (e.g., NPI, BCMA patch for IHS HRN) IHS presence at Tech Talk 2006http://vista.med.va.gov/techconf/2006/ Sample of topics Moving From VistA to HeV Five Essential Differences Between System of System Development and Traditional System Development The New Competency-aligned Organization M and Java: Move to Object Oriented Technologies M Editor for Eclipse Section 508 Identity Management - the Master Patient Index (MPI) and Beyond Human Factors Engineering Principles HIA Enterprise Solution Architecture & Architecture Assurance Programs SOA and How It Applies to HealtheVet CDS for reengineered applications Automated Installation of Linux for Oracle & WebLogic Don't Drown in the Flood of Change Engagement in 100-day projects (pending) Clayton Curtis MD PhD

32. What’s the state of VHA-IHS network interconnection? Clayton Curtis MD PhD

33. VHA-IHS VPN tunnel operating Basically IHS->VHA only (special DNS, ACL) Links to selected sites posted on collaboration site (vhacollaboration.ihs.gov) Sites include development sites, training materials (VeHU/Camp CPRS), organizational sites, and more Currently, specifically NOT for clinical data Work starting on agreements to support applications involving clinical data Consolidated Mail Out Pharmacy (CMOP) Lab services Remote radiology interpretation Clayton Curtis MD PhD

34. Whatever happened to VistA Office EHR? Clayton Curtis MD PhD

35. VistA Office EHR and CMS “Through the VistA-Office Electronic Health Record (EHR) project, CMS is working with the Veterans Health Affairs (VHA) to transfer health information technology to the private sector. CMS is funding and collaborating with VHA and other key federal agencies on the development of a VistA-Office EHR version of the VHA's hospital VistA system for use in clinics and physician offices. An overriding goal of VistA-Office EHR is to stimulate the broader adoption and effective use of EHRs by making a robust, flexible EHR product available in the public domain.” From the CMS project website: www.cms.hhs.gov/quality/pfqi.asp Clayton Curtis MD PhD

36. Project timetable • In mid-March, CMS provided VOE Beta Version 1.0 to five qualified vendors, for installation at ten test sites. • In May, another contractor began work on an independent evaluation. • The results of a gap analysis between VOE Beta Version 1.0 and the HHS interoperability standards are due to CMS on June 22nd. Results of the independent evaluation are due to CMS on December 1st. • The Beta test is scheduled to conclude at the end of January 2007. Decisions on release / deployment will follow. Clayton Curtis MD PhD

37. What’s happened with MyHealtheVet? Clayton Curtis MD PhD

38. MHV is on track… Iterative Implementation Releases: November 2003 November 2004 – November 2005 Two Major Releases – CY06 Registration of Pts User-Centered Design Graphing Self-Entered Information Personalization Family & Past Medical Health Histories Pt Education Content Self-Entered Metrics Health Tools VistA EHR Prescription Refill Food Journal VA Services Future Releases Activity Journal Patient Provider Messaging Pulse Oximetry Delegation Calendaring Treatment Plans Clayton Curtis MD PhD

39. Memorial day 2006 release • Create Graphs – Ability for patients to generate simple visual graphs of their health readings. Patients can select health readings they would like to see graphed. • Create Health Histories – Patients have an area to record personal and family health histories. Patients can share health histories with their health care providers. • Create a Doctor Sheet – A comprehensive view of the entire patient’s health history in a summary view that can be printed out and taken to appointments. Clayton Curtis MD PhD

40. Total visits exceed 4,000,000 2005 = MHV 1,000,000 visits in ~ 8 months 2006 = MHV 1,000,000 visits in ~ 2 months 500,000 prescription refills in 4 months My HealtheVet Usage Clayton Curtis MD PhD

41. What’s the bottom line? Clayton Curtis MD PhD

42. VHA is staying the course… • Reorganization expected to result in better alignment of development with clinical business priorities and to meet Congressional expectations for control and accountability • HeV timelines extended, but strategy remains the same. • Dedication to strategic partnership with IHS remains unchanged. Clayton Curtis MD PhD

43. More Questions? Clayton.Curtis@med.va.gov Clayton Curtis MD PhD