Enabling Health Care Efficiencies via an Interoperable Health Record

1. Enabling Health Care Efficiencies via an Interoperable Health Record Paul Tibbits Deputy CIO for Enterprise Development Department of Veterans Affairs November 12, 2009

2. Interoperability: Current and Planned

3. Current State Compensation & Pension Data MGIB Program Usage Data Military Service Imaged Record via DPRIS HEC IM/IT WORK GROUP BEC IS/IT WORK GROUP Pharmacy Data Allergy Data Lab Results Discharge Summaries Std Ambulatory Data Record Combat Military Pay Accessions & Separations Activation / Mobilization Military Pay Information Radiology Reports Post-Deploy Assessment Theater Clinical Data Pre-Deploy Assessment Post-Deploy Reassessment MGIB Eligibility Information Add’l Education Benefit Data UIC Mailing Address Data Insurance/ Benefit Eligibility Inpatient Consults Operative Reports Provider Notes Procedures Problem Lists Social History Other History Family History Vital Signs Additional Inpatient Data Member / Veteran Family Member Information for Insurance and Cemetery Benefits Questionnaires Plan Completed Jun 08 Plan Completed Jun 08 Inpatient Documentation Expansion Sep 09 DoD and VA Shared Personnel / Administrative Data Images (Enterprise-Wide) Images (Enterprise-Wide) Gateways - Data Migration DoD and VA Shared Health Data Sep 09 Interoperability Plan, V 1.0 Completed Sep 08 Interoperability Plan, V 1.0 Completed Sep 08 Add’l Data Elements (Viewable) Add’l Data Elements (Viewable) Document Scanning (initial) Sep 09 Add’l Data Elements (Computable) Add’l Data Elements (Computable) Expansion of Questionnaires Sep 09 Lab Results (computable) Oct 09 Clinical Enhancements Defense Center of Excellence (DCOE) Phase 1 of Common Services Initiative Phase 2 of Common Services Initiative Dis Eval Sys Pilot - VTA Tracking (LOA1) Wounded Warrior Indicators (LOA4) eBenefits Portal (LOA4) Cognitive Assessment Tool (LOA2) Web-Based Training (LOA2) TBI / PTSD Telehealth Consult (LOA2) Document Mgmt. System (LOA1) VA Disability Exam Templates (LOA1) Imaging - Theater (LOA4) TBI Extender Codes (LOA2) Research Clearing / Data-mart (LOA2) Clinical Case Mgmt. (LOA3) Web-Based FIRP (LOA3) KEY Current Sharing (Viewable) Current Sharing (Computable) Reserve Health Records Access (LOA4) Behavioral Health Notes (LOA2) TBI Patient Registry (LOA2) ADT to DFAS (LOA8) Non-Clinical Case Mgmt. (LOA3) Planned Sharing (funded) Potential Sharing (unfunded & uncosted) Potential Sharing (DoD funded) Potential Sharing (VA funded; DoD identified funding requirements – FY09 supplemental) On Contract 3

4. North Chicago – Captain James A. Lovell Federal Health Care Center First FHCC managed jointly by VA and DoD Opening Day October 2010 • On Schedule • Provide Information Management/Information Technology • Key to establishing VA/DoD electronic health record 4 Ambulatory Care Center site

5. Proposed Future State Other Government Agencies Beneficiary / Stakeholder Managed Care / Fee Private Providers Common Services Other Uniformed Services DoD VA Army Single Sign-On Service History Benefits & Eligibility Pharmacy* Lab* Marine Corps VHA Portable Order Entry Radiology* Navy VBA Compensation Air Force Self-Service Logon Identity Management NCA Consults JOINT Education DoD Unique Data Ex: Enrollment, Operational/Theater Information VA Unique DataEx: Extended Care Data, Veteran/Dependent Benefits Virtual Lifetime Electronic Record Health | Benefits | Personnel Medical Care: Theater & Home VA Extended Care Survivor Benefits Compensation Deployment Personnel Data Accession Training Readiness Education Separation Memorials 5 * Orders and results

6. State and Local Gov Health Bank orPHR Support Organization Community Health Centers CMS CDC VA DoD SSA Community #1 Labs IntegratedDelivery System Pharmacies Nationwide Health Information Network Mobilizing Health Information Nationwide Community #2 The Internet Standards, Specifications and Agreementsfor Secure Connections

7. Architecture and Technical Challenges

8. Top 10… SOA General Misconceptions 10. Orchestration = dynamic discovery = dynamic consumption 9. Configurable = loosely coupled 8. Identity is Identity, and there is only 1 7. SOA is a “Big Bang Theory” 6. Granularity of services is easy to define 5. Standards and Specifications compliance is strictly defined 4. WSDL exchange = interoperability 3. Security and auditing can be retrofitted Service-Oriented Architectures are primarily a technical or management approach And the #1 General misconception is… 1. SOA is the answer to interoperability (and you can buy one)

9. Approaching Service Orientation FEA VA Pillars Governance VHA E-SOA Governance Strategic Goals & Objectives VBA NCA Domains of Value BRM VBA Strategy NCA Strategy Eight for Excellence Requirement Framework Medical Care Medical Research Medical Education VBALines of Business NCA Lines of Business Business Components (Functions, Sub-functions, and Capabilities Organizational Governance Care Mgmt PRM VBABusiness Area NCA Business Area Employee Health Record Open Community Process VBASub-Functions NCASub-Functions Sub-Function 1 Sub-Function 2 Sub-Function 3 Sub-Function 4 Business Process Modeling Information Element 4 DRM Information & Data Information Element 1 Information Element 6 VBA Information Element Data Strategy NCA Information Element Information Element 2 Information Element 3 Information Element 5 Metrics NCA Service VHA Service Applications VBA Service VBA Service Test &Assessment SRM VBA Service NCA Service Service 3 NCA Service 6 Service 1 Certification & Accreditation … VBA Service 4 Service 1 Services 2 Service n VBA Service 6 NCA Service 6 Services Composite Apps Deployment Strategy Infrastructure Components Messaging Discovery Security ESM Education & Training Core Services TRM Technical Standards • Strategic Governance needs to enforce the “design by standards” approach versus “design by product” across the Enterprise • Critical elements required to scale Tactical Governance Model • Enterprise review boards • Programmatic Governance Boards: Enterprise Management Processes • Functional Governance Boards: portfolio and capability establishment • Technical Governance Boards • Roadmap for core services utilized by all development efforts • Reference Architecture to enable experimentation and development including Standards, Specifications, Patterns and Practices (SSPPs) 9 VA Internal Use Only

10. Example: Chapter 33 Tactical Governance Chapter 33 Tactical Governance • Identifying and managing critical gaps in Governance for Chapter 33 • Process and artifacts that: • Identify connection to systems outside CH33 • Determine responsibility for changes to these systems • Determine service agreement type • Enable CH33 service deployment and certification • Developing service-oriented Standards, Specifications, Patterns and Practices (SSPP) and an associated reference implementation of core services ESOA / Ch 33 Arch IPT Charter SPAWAR (Chair) Ch 33 Technical Team VBA-SE EIE OED-SE OED / Ch 33 Arch-Eng Governance Board Charter OED-SE (Chair) VBA Architect PM Rep EIE Rep BOIBI Rep Field Ops Security • Implementing Governance for Chapter 33 • Established OED / Chapter 33 Architecture and Engineering Governance Board • Established ESOA / Chapter 33 Architecture Integrated Product Team (IPTs) to manage issues in key areas • Security, Architecture, Infrastructure Chapter 33 Governance Model is scalable to the Enterprise level 10 VA Internal Use Only

11. Innovation

12. Innovation Components Greenfield Incubation—field innovators propose new opportunities Strategic Incubation*—leadership identifies opportunities Innovation Diffusion—evaluation of the quality of products and how products work in the healthcare delivery process Collaborative Tools—technologies used to advance innovation and encourage the building of communities of interest Workforce Development—activities undertaken to build a culture of innovation and a knowledgeable workforce VA OI&T Innovation Advancement Program (IAP) *cross-Administration strategic initiatives to be undertaken; points of contacts have been identified 12

13. Innovation Evaluation • Innovation criteria • Improves patient care (e.g., safety, quality or access) • Improves efficiency (e.g., clinical workflow or cost/benefit) • Impacts numerous Veterans, staff or other stake holders • Addresses an unmet need rather than incrementally improves existing methods • Helps meet an organizational requirement (e.g., Joint Commission or Congressional mandate) • Three review teams, five reviewers per team with multi-discipline and leadership level mix • Preliminary Review Process: • Addressed Conflicts of Interest • Randomly assigned LOI to teams • Used blinded independent review with established Innovation Evaluation Criteria on 1-5 scale • Group discussed and determined final scoring • Final Review Process and Criteria: • Same review teams, evaluated full proposals • Benefit factors: Quality, Efficiency, Scope, Novelty, Requirement • Feasibility factors: Team, Approach, Environment

14. Greenfield Award Overview 44 TOTAL CONCEPTS SELECTED FOR FUNDING

15. Program Management and Acquisitions

16. Analysis of Ongoing VA Programs 280+ programs reviewed 8 program attributes analyzed Many programs exhibited signs of trouble Greater than 13 months behind schedule Greater than 50% over initial cost estimate Decrease in software quality between releases Inadequate skills to complete program Substantial change required 16

17. Incremental Development All new VA IT projects/programs must use an incremental development approach Frequent customer delivery milestones at maximum of six months Customer must test and accept functionality To be approved for investment, a program or project must have: An identified customer sponsor and integrated project team (IPT) Program plan that documents frequent delivery milestones Documented, agreed to requirements for initial milestones Clear plan for necessary program disciplines Clear access to necessary program resources Customer, program, and vendor acceptance of PMAS Jointly established success criteria 17

18. Program Management Accountability System (PMAS) All incremental development programs will be managed rigorously to schedule A program/project will be halted on its third missed customer delivery milestone Once halted, substantial changes must be made before the program can restart Need for program/project will be re-assessed Program approach will be re-assessed Make/buy and program design decisions will be re-assessed Program management assignment will be revisited Government staff assignments will be revisited All service contracts will be re-visited New program plan must be approved Flexibility can be earned Collaboration is key to IT success. 18

19. Acquisitions • Established a dedicated acquisition office to support OIT program planning and execution • Provide life cycle acquisition support from program inception through completion by a multi-functional IPT • Implementing joint Program Management Reviews to improve contract performance and program execution • Collaboration with industry through early involvement of requirements and transparency Acquisitions plays a dedicated and integral role in project IPTs.

20. Conclusions • Investment vs. Value • Consensus of IT “Sellers” and “Buyers” on Business Need • Need for Incentives • Information Interoperability • Collaboration at all Levels Essential • Rigorous Program Management and Acquisitions Process