HEALTH INFORMATICS TO IMPROVE PATIENT CARE

1. HEALTH INFORMATICS TO IMPROVE PATIENT CARE VA Transformational Initiatives for the 21st Century

2. HEALTH INFORMATICS Definition: Health Informatics applies the principles of computer and information science toward the management of patient care processes and work flow. Goal: To understand and promote effective organization, analysis, management, and use of information in health care Examples: Codify clinical guidelines Support the implementation of clinical processes and clinical decision support systems Standardize medical terminologies Enhance the relationships between treatments and results to optimize clinical outcomes. 2

3. 3 U.S. HIT STRATEGIC FRAMEWORK Many current national Health IT and Informatics and trends are captured in the US Health IT Strategic Framework pictured here. Central to the framework are that data and information at both the individual and population health levels are the drivers for a learning health system, or a �healthy health system.� A learning health system is designed to generate and apply the best evidence for the collaborative health care choices of each patient and provider (team); to drive process of new discovery as a natural outgrowth of patient care; and to ensure innovation, quality, safety, and value in health care. (Charter of the Institute of Medicine Roundtable on Value and Science-Driven Health Care.) A learning health system focuses on the needs of both individuals and population health and aims to be patient-centered, safe, timely, effective, efficient, and equitable while protecting privacy and confidentiality of health information. In a learning health system, individuals can make informed decisions about their health and health care; patients can exercise informed choices about sharing their data; decision makers have access to the right information at the right time in a secure environment; the health delivery system is more efficient; and all participants in the system contribute to improving population health. Many current national Health IT and Informatics and trends are captured in the US Health IT Strategic Framework pictured here. Central to the framework are that data and information at both the individual and population health levels are the drivers for a learning health system, or a �healthy health system.� A learning health system is designed to generate and apply the best evidence for the collaborative health care choices of each patient and provider (team); to drive process of new discovery as a natural outgrowth of patient care; and to ensure innovation, quality, safety, and value in health care. (Charter of the Institute of Medicine Roundtable on Value and Science-Driven Health Care.) A learning health system focuses on the needs of both individuals and population health and aims to be patient-centered, safe, timely, effective, efficient, and equitable while protecting privacy and confidentiality of health information. In a learning health system, individuals can make informed decisions about their health and health care; patients can exercise informed choices about sharing their data; decision makers have access to the right information at the right time in a secure environment; the health delivery system is more efficient; and all participants in the system contribute to improving population health.

4. HEALTH INFORMATICS: CENTRAL TO PRIOR & FUTURE VA TRANSFORMATION 4 VA has a rich history of using health IT and health informatics to improve patient care and health care delivery. Many have chronicled the value of VistA and the Computerized Patient Record system (CPRS) as well as other VA tools and informatics resources. CPRS has been characterized as the �crown jewel� of VistA. CPRS transitioned VHA from a collection of information systems serving needs of hospital departments to an integrated patient-centered information system. This paradigm shift had far-reaching impacts on improved clinical quality and patient safety. The accolades of past achievements serve as a gauge for future endeavors. VA�s 21st Century Transformation will again rely heavily on Health Informatics and development of VA Health Informatics capacities is fundamental to continuation of VA�s role as a leader in health information technology. VA has a rich history of using health IT and health informatics to improve patient care and health care delivery. Many have chronicled the value of VistA and the Computerized Patient Record system (CPRS) as well as other VA tools and informatics resources. CPRS has been characterized as the �crown jewel� of VistA. CPRS transitioned VHA from a collection of information systems serving needs of hospital departments to an integrated patient-centered information system. This paradigm shift had far-reaching impacts on improved clinical quality and patient safety. The accolades of past achievements serve as a gauge for future endeavors. VA�s 21st Century Transformation will again rely heavily on Health Informatics and development of VA Health Informatics capacities is fundamental to continuation of VA�s role as a leader in health information technology.

5. DELIVERING EVIDENCE BASED CARE 5 More on past success and specifically how health informatics has impacted performance measures assessing evidence based care. Applying Health Informatics in the form of Clinical Guidelines, Clinical Reminders, and other strategies have enabled VA to consistently deliver evidence based preventive care and many chronic disease interventions. Next generation tools will take this to another level by allowing us to use our data in new ways that go beyond implementing clinical guidelines. Example: In the future we envision the capability to not only ensure that the cancer screening was completed, but what the impact was on outcomes and how we can use that information to adapt and change our care models and interventions.More on past success and specifically how health informatics has impacted performance measures assessing evidence based care. Applying Health Informatics in the form of Clinical Guidelines, Clinical Reminders, and other strategies have enabled VA to consistently deliver evidence based preventive care and many chronic disease interventions. Next generation tools will take this to another level by allowing us to use our data in new ways that go beyond implementing clinical guidelines. Example: In the future we envision the capability to not only ensure that the cancer screening was completed, but what the impact was on outcomes and how we can use that information to adapt and change our care models and interventions.

6. VA�S CURRENT CHALLENGE The world leader in using Information Technology (IT) to deliver higher quality, lower cost healthcare to patients, VA is at risk for moving into a non-sustainable position that threatens not only VA�s IT leadership, but also patient health. An aging and unsustainable health IT model Inefficient, process-laden development models Unable to support VA strategic goals and integrated objectives. 6 VA faces a number of challenges as a large health care enterprise. Most of these are not unique to VA, and wider experience in the health care industry suggests that health IT / informatics is a key to facing them successfully. Overarching challenges include: Major shifts in its basic models for delivery of health care services; The need to increase provider performance as well as job satisfaction; The sharing of patient care with Federal and non-Federal sources of patient care; Societal expectations for increased involvement of patients in their own care and decision making, as well as satisfaction with their providers and their health care system; A requirement for more agile and anticipatory capacity planning and program management based on knowledge of population health. VA faces a number of challenges as a large health care enterprise. Most of these are not unique to VA, and wider experience in the health care industry suggests that health IT / informatics is a key to facing them successfully. Overarching challenges include: Major shifts in its basic models for delivery of health care services; The need to increase provider performance as well as job satisfaction; The sharing of patient care with Federal and non-Federal sources of patient care; Societal expectations for increased involvement of patients in their own care and decision making, as well as satisfaction with their providers and their health care system; A requirement for more agile and anticipatory capacity planning and program management based on knowledge of population health.

7. Most VA Transformational Initiatives have underlying IT and informatics dependencies. Common themes include: Web-based applications Enterprise-wide and Patient-centric data Registries, Tracking and Reporting COTS software integration Recommendations in 2010 VistA Modernization Report by the American Council for Technology/ Industry Advisory Council, GAO and other reviewers VA�s 2010 Open Government Plan 7 The current IT architecture and development model does not provide adequate support for the common IT project needs across the other T21 Initiatives. The VistA Modernization Report was developed by a 42-member group of industry healthcare and IT professionals. The group recommended modernization of VistA to an open-source, open-standards environment. Modernization is also reinforced by Secretary Shinseki�s VA Open Government Plan, which announced VA�s movement toward a modular, Web-enabled electronic health record system that can be easily and remotely maintained. This change promotes Open Government by creating an environment that supports true collaboration among the health care team, with Veteran patients and with our DoD and community partners. The current IT architecture and development model does not provide adequate support for the common IT project needs across the other T21 Initiatives. The VistA Modernization Report was developed by a 42-member group of industry healthcare and IT professionals. The group recommended modernization of VistA to an open-source, open-standards environment. Modernization is also reinforced by Secretary Shinseki�s VA Open Government Plan, which announced VA�s movement toward a modular, Web-enabled electronic health record system that can be easily and remotely maintained. This change promotes Open Government by creating an environment that supports true collaboration among the health care team, with Veteran patients and with our DoD and community partners.

8. Healthcare Teams need Role and context-specific interfaces to clinical systems Greater support for workflow and cognitive tasks More powerful and integrated clinical decision support 8 More powerful and integrated clinical decision support Moving beyond interrupt driven pop-up alerts and reminders driven by static guidelines to �knowledge driven �just-in-time� access to information that takes advantage of VA�s enormous accumulated experience. More powerful and integrated clinical decision support Moving beyond interrupt driven pop-up alerts and reminders driven by static guidelines to �knowledge driven �just-in-time� access to information that takes advantage of VA�s enormous accumulated experience.

9. Successful patient care depends on participation by activated patients Personal Health Record Patient-oriented health libraries Modern communication tools Self-management tools 9 Patients need: More access to their personal health records Information to guide informed decision-making Robust communication tools for interacting with their care team, and Tools for understanding and addressing their health issues. Patients need: More access to their personal health records Information to guide informed decision-making Robust communication tools for interacting with their care team, and Tools for understanding and addressing their health issues.

10. Successful heath care depends on a functional healthcare system The system of records reflects the performance of the healthcare delivery process Registries and cohort management tools inform both quality and performance management Intra- and inter-system performance comparisons provide transparency into a system�s health. 10 Patients need: More access to their personal health records Information to guide informed decision-making Robust communication tools for interacting with their care team, and Tools for understanding and addressing their health issues. Patients need: More access to their personal health records Information to guide informed decision-making Robust communication tools for interacting with their care team, and Tools for understanding and addressing their health issues.

11. Electronic Health Platforms Support (optimize) an individual patient�s care Are the portal through which patients engage with health systems in a longitudinal fashion Are the foundation upon which population health management is built. 11 Much of VA�s data is in a text format that is not usable by IT systems. VA must collect more data in computable form and to collect the right computable data. This is essential to quality care of the individual patient, management of population health, and research. VA�s assemblage of clinical data systems must be designed and orchestrated in a proactive fashion to support research and analytics that inform patient care and system management. Much of VA�s data is in a text format that is not usable by IT systems. VA must collect more data in computable form and to collect the right computable data. This is essential to quality care of the individual patient, management of population health, and research. VA�s assemblage of clinical data systems must be designed and orchestrated in a proactive fashion to support research and analytics that inform patient care and system management.

12. Data is only of value when aggregated in a usable mode by IT systems Text-based entries are not routinely useable Exception for very focused areas where limited elements are collected Non-computable fields are standardization challenges (and nightmares) Rarely can support health systems needs, including billing, research and analytics 12 Much of VA�s data is in a text format that is not usable by IT systems. VA must collect more data in computable form and to collect the right computable data. This is essential to quality care of the individual patient, management of population health, and research. VA�s assemblage of clinical data systems must be designed and orchestrated in a proactive fashion to support research and analytics that inform patient care and system management. Much of VA�s data is in a text format that is not usable by IT systems. VA must collect more data in computable form and to collect the right computable data. This is essential to quality care of the individual patient, management of population health, and research. VA�s assemblage of clinical data systems must be designed and orchestrated in a proactive fashion to support research and analytics that inform patient care and system management.

13. INITIATIVE 16: A New INITIATIVETRANSFORMING HEALTH CARE DELIVERY THROUGH HEALTH INFORMATICS VA Transformational Initiative for the 21st Century 13 The urgency to change is clear. The time to transform is now. The rest of our session will be focused on VA�s new Transformational Initiative #16, Transforming Health Care Delivery Through Health Informatics or Health Informatics Initiative. Creation of the T16 initiative was driven in large part by two realizations: that the majority of the Secretary�s transformational initiatives depend on enhanced clinical information systems and that development of clinical applications software is not occurring at the level required. VHA is currently addressing a number of major priorities, including (a) establishing the patient care medical home model; (b) delivering more specialty care on virtual basis; (c) making more information available to patients; (d) increasing communication between teams. The intent is for T16 to support and complement such efforts This new initiative was kicked off in May of this year and is quickly moving ahead. The urgency to change is clear. The time to transform is now. The rest of our session will be focused on VA�s new Transformational Initiative #16, Transforming Health Care Delivery Through Health Informatics or Health Informatics Initiative. Creation of the T16 initiative was driven in large part by two realizations: that the majority of the Secretary�s transformational initiatives depend on enhanced clinical information systems and that development of clinical applications software is not occurring at the level required. VHA is currently addressing a number of major priorities, including (a) establishing the patient care medical home model; (b) delivering more specialty care on virtual basis; (c) making more information available to patients; (d) increasing communication between teams. The intent is for T16 to support and complement such efforts This new initiative was kicked off in May of this year and is quickly moving ahead.

14. INITIATIVE LEADERSHIP Executive Sponsor: Robert Jesse, MD, PhD Sponsor: Madhu Agarwal, MD, MPH Sponsor: Cathy Rick, RN, NEA-BC, FACHE VHA Lead: Tana Defa OI&T Lead: Michael Braithwaite Operational Sponsor: Daniel Hoffmann, FACHE 14

15. HEALTH INFORMATICS INITIATIVE Purpose: to shape the future of VHA clinical information systems through a deliberate application of health IT and informatics to: Deliver solutions that transform Veterans health care, improving quality and accessibility while optimizing value Enable VA to continue its industry leadership in the use of health informatics and health information technology 15 The Health Informatics Initiative presents an opportunity to embark on a new journey, exploring and developing health delivery software solutions that extend the scope of VA�s health information technology from an electronic health record to a health management platform. This Initiative is the catalyst that will remove communication barriers and promote collaboration between health care providers and software development teams. It will facilitate effective communication, trust, respect, and understanding between the technical and business owners through establishment of a relationship strengthened by shared responsibility and accountability. The Health Informatics Initiative presents an opportunity to embark on a new journey, exploring and developing health delivery software solutions that extend the scope of VA�s health information technology from an electronic health record to a health management platform. This Initiative is the catalyst that will remove communication barriers and promote collaboration between health care providers and software development teams. It will facilitate effective communication, trust, respect, and understanding between the technical and business owners through establishment of a relationship strengthened by shared responsibility and accountability.

16. INTENDED OUTCOMES Raise the role of Informatics and Health IT from a systems of individual records (EHR) to that of a comprehensive health management platform (HMP) Provide quality and accessibility of health care to Veterans while optimizing value Facilitate/Accelerate VA�s transition from a medical model to a patient-centered model of care Build a sustainable collaborative approach, capacity, and facile tools to promote informatics solutions that will transform health care delivery to Veteran Ensure continued industry leadership in applied health informatics 16

17. OPERATIONAL CONCEPT The conceptual model for the Health Informatics Initiative is to create an iterative development process based on successive close interactions between the users and development community which results in cross learning, mutual understanding , and a better product than can be developed if either group remains isolated.� The Initiative establishes a VHA/OI&T collaborative to streamline software development for healthcare team-facing, patient-facing and population-based health management platforms. The proposed solutions are Veteran-centric and improve information sharing and population health outcomes in terms of access, quality and safety while improving provider efficiency and satisfaction with the health management software. The Initiative embraces participatory medicine and encourages increased patient and family involvement in their care and decision-making. Evidence-based care for preventive and chronic disease management will be supported as will clinical decision support tools that are knowledge-driven and context sensitive with patient-specific computable data. The delivery of health care will be more specific to the individual Veterans yet utilize treatment regimens validated through population studies.The conceptual model for the Health Informatics Initiative is to create an iterative development process based on successive close interactions between the users and development community which results in cross learning, mutual understanding , and a better product than can be developed if either group remains isolated.� The Initiative establishes a VHA/OI&T collaborative to streamline software development for healthcare team-facing, patient-facing and population-based health management platforms. The proposed solutions are Veteran-centric and improve information sharing and population health outcomes in terms of access, quality and safety while improving provider efficiency and satisfaction with the health management software. The Initiative embraces participatory medicine and encourages increased patient and family involvement in their care and decision-making. Evidence-based care for preventive and chronic disease management will be supported as will clinical decision support tools that are knowledge-driven and context sensitive with patient-specific computable data. The delivery of health care will be more specific to the individual Veterans yet utilize treatment regimens validated through population studies.

18. INITIATIVE PROJECTS Establish a VHA/OI&T collaborative supporting rapid product development and delivery Create a Health Management Platform to Transform Patient Care Provider team-Facing � Patient-Facing Health System-Facing Build Health Informatics Capacities system wide 18 The Health Informatics Initiative is composed of three major workstreams which will be described more fully in subsequent slides. The three workstreams were visually represented on the previously slide, but to recap more clearly they are to: Establish a VHA/OI&T collaborative supporting rapid product development and delivery - In the collaborative model, Patient Care Services (PCS), Office of Nursing Services (ONS) and Office of Health Information (OHI) are partners in representing VHA. This workstream implements an extensible and sustainable collaborative approach to streamline software development. Central to that approach is a new methodology for collaborative, iterative requirements identification and elaboration that occurs throughout the development process.� 2. Create a Health Management Platform to Transform Patient Care � This workstream involves evolving CPRS to 3 transformational platforms: Healthcare Team-facing Patient-facing Population-Based The Initiative is a pathway for modernization of the Health Management Platform. It does not subsume Information Technology (IT) development. The Health Informatics Initiative will use agile development techniques to produce next generation Health Information Technology (HIT) prototypes that support the health care team. As with CPRS, successful implementation will require cultural, informational, and technological paradigm shifts that support cognition, communication and workflow of patients, clinicians and population-health practitioners. 3. Build Health Informatics Capacities �grows and develops our health informatics expertise to establish sustainable workforce capacity that supports healthcare modernization and improved care delivery through health informatics. Each of these workstreams will generate tangible deliverables in FY11, 12 and 13. The Health Informatics Initiative is composed of three major workstreams which will be described more fully in subsequent slides. The three workstreams were visually represented on the previously slide, but to recap more clearly they are to: Establish a VHA/OI&T collaborative supporting rapid product development and delivery - In the collaborative model, Patient Care Services (PCS), Office of Nursing Services (ONS) and Office of Health Information (OHI) are partners in representing VHA. This workstream implements an extensible and sustainable collaborative approach to streamline software development. Central to that approach is a new methodology for collaborative, iterative requirements identification and elaboration that occurs throughout the development process.� 2. Create a Health Management Platform to Transform Patient Care � This workstream involves evolving CPRS to 3 transformational platforms: Healthcare Team-facing Patient-facing Population-Based The Initiative is a pathway for modernization of the Health Management Platform. It does not subsume Information Technology (IT) development. The Health Informatics Initiative will use agile development techniques to produce next generation Health Information Technology (HIT) prototypes that support the health care team.

19. 1. ESTABLISH A VHA/OI&T COLLABORATIVE SUPPORTING RAPID PRODUCT DEVELOPMENT AND DELIVERY Define the technical, business, cultural and architectural strategy Establish a governance structure for migrating from current to future environment Develop Knowledge Management program 19 In addition to the Initiative�s collaboration of ONS, OHI and PCS within VHA, collaboration with OI&T must occur for us to move forward successfully. Over the years we have shifted away from an approach in software development that got us to the system we have in use today. In the current model, business owners and technical staff are separated in the development process. This Initiative will explore opportunities for overcoming barriers that have prevented effective communication and collaboration between the business owners and the technical staff and move toward truly interactive collaboration that increases the domain knowledge and expertise in the partnership. It is critical that VHA partner with OI&T to establish an approach to the creation of information systems that is driven by health informatics requirements/needs. This work stream/project is focused on getting to just that. Efforts will be applied to establishing methodologies to partner subject matter experts with the development teams to bring technology to the end users. A rapid product development and delivery environment will be created by using various agile and iterative development approaches. This sub-initiative is complex, but 3 key areas highlighted on the slide require intense focus In order to accomplish this it is critical that we review technology, business, cultural and architectural approaches we are taking today and then define what is needed in those areas in order to be successful. Within any new approach it is critical that roles, responsibilities are established. We too will need to establish a governance structure that supports the effort to migrate to the future environment. And last but not least, we need to figure out how to build the linkages between informatics and IT solution. The creation of knowledge management program will assist us in doing just that. This next paradigm shift can be accomplished if the lessons from CPRS are embraced. In addition to the Initiative�s collaboration of ONS, OHI and PCS within VHA, collaboration with OI&T must occur for us to move forward successfully. Over the years we have shifted away from an approach in software development that got us to the system we have in use today. In the current model, business owners and technical staff are separated in the development process. This Initiative will explore opportunities for overcoming barriers that have prevented effective communication and collaboration between the business owners and the technical staff and move toward truly interactive collaboration that increases the domain knowledge and expertise in the partnership. It is critical that VHA partner with OI&T to establish an approach to the creation of information systems that is driven by health informatics requirements/needs. This work stream/project is focused on getting to just that. Efforts will be applied to establishing methodologies to partner subject matter experts with the development teams to bring technology to the end users. A rapid product development and delivery environment will be created by using various agile and iterative development approaches. This sub-initiative is complex, but 3 key areas highlighted on the slide require intense focus In order to accomplish this it is critical that we review technology, business, cultural and architectural approaches we are taking today and then define what is needed in those areas in order to be successful. Within any new approach it is critical that roles, responsibilities are established. We too will need to establish a governance structure that supports the effort to migrate to the future environment. And last but not least, we need to figure out how to build the linkages between informatics and IT solution. The creation of knowledge management program will assist us in doing just that. This next paradigm shift can be accomplished if the lessons from CPRS are embraced.

20. Software Requirements Identified Through Exploration�and Discovery Iterative Development Senior Developers with Domain Knowledge Product Line Development Teams Continuous Improvements/Evolution End User � Developer Collaboration 20 LEARNING FROM PAST SUCCESSLESSONS FROM CPRS The factors that made CPRS development a success were: Software Requirements Identified Through Exploration�and Discovery: Clinicians as development partners defined the clinical problem space on an ongoing basis. Developers listened intently, learned about processes and observed users role-playing workflow exercises using requirements collaboration principles Iterative Development (Rapid-Cycle): Developers designed prototypes, assessed reactions to prototypes, and then adjusted the software to accommodate the identified needs. Keen awareness, through technical observation and business owner assessment of implementation issues and human adaptation challenges resulted in software refinements and enhancements. Developers as Senior System Designers with Valued and Nurtured Domain Expertise: CPRS developers worked at the senior system designer level and provided continuity with long-term commitments as opposed to responding to a set of requirements typically transferred to coders or programmers for a short-term project. Cohesive Product Line Teams based on Natural Business Subsystems: CPRS development team was small and cohesive. Natural subsystems such as Lab, Pharmacy and Radiology evolved and functional and technical expertise was continually sought and developed to support them. Developers served long term, knew the product, understood the business and had established credibility and business owner relationships Continual Advancement of Core Products for Continuously Improved Interface and Usability CPRS continuously improved due to clear roles and actions at the national and local level. The national development teams served as advocates and stewards for strategic planning and fundamental changes at the core product line level with acute awareness of national requirements related to design, supportability, extensibility, and portability. Local (facility-based) CPRS development teams were closest to urgent front line needs and problems which allowed them to enhance and fine-tine the current environment based on local requirements (Class III development.) Continuous Partnership between Business Owner and Developers: CPRS was the result of an ongoing partnership between technical and clinical (business owner) staff who met to discuss workflow process and identify problems related to their daily needs in delivering health care. Clinicians defined the clinical problem space, processes and workflows while development staff identified the associated technical opportunities and constraints. Collaborative discussions converged isolated perspectives resulting in consensual decision-making about the appropriate interface to meet functional needs in a sound, forward-facing technical environment. The factors that made CPRS development a success were: Software Requirements Identified Through Exploration�and Discovery: Clinicians as development partners defined the clinical problem space on an ongoing basis. Developers listened intently, learned about processes and observed users role-playing workflow exercises using requirements collaboration principles Iterative Development (Rapid-Cycle): Developers designed prototypes, assessed reactions to prototypes, and then adjusted the software to accommodate the identified needs. Keen awareness, through technical observation and business owner assessment of implementation issues and human adaptation challenges resulted in software refinements and enhancements. Developers as Senior System Designers with Valued and Nurtured Domain Expertise: CPRS developers worked at the senior system designer level and provided continuity with long-term commitments as opposed to responding to a set of requirements typically transferred to coders or programmers for a short-term project. Cohesive Product Line Teams based on Natural Business Subsystems: CPRS development team was small and cohesive. Natural subsystems such as Lab, Pharmacy and Radiology evolved and functional and technical expertise was continually sought and developed to support them. Developers served long term, knew the product, understood the business and had established credibility and business owner relationships Continual Advancement of Core Products for Continuously Improved Interface and Usability CPRS continuously improved due to clear roles and actions at the national and local level. The national development teams served as advocates and stewards for strategic planning and fundamental changes at the core product line level with acute awareness of national requirements related to design, supportability, extensibility, and portability. Local (facility-based) CPRS development teams were closest to urgent front line needs and problems which allowed them to enhance and fine-tine the current environment based on local requirements (Class III development.) Continuous Partnership between Business Owner and Developers: CPRS was the result of an ongoing partnership between technical and clinical (business owner) staff who met to discuss workflow process and identify problems related to their daily needs in delivering health care. Clinicians defined the clinical problem space, processes and workflows while development staff identified the associated technical opportunities and constraints. Collaborative discussions converged isolated perspectives resulting in consensual decision-making about the appropriate interface to meet functional needs in a sound, forward-facing technical environment.

21. 2. CREATE A HEALTH MANAGEMENT PLATFORM TO TRANSFORM PATIENT CARE Healthcare Team*-Facing � Patient-Facing Health System -Based 21 Transformative change in the integration of informatics and health IT in the delivery of health care requires attention to three areas: transforming the healthcare team experience, increasing patient engagement and satisfaction, and addressing population-based aspects of care. Each of these areas: Team, Patient, and Population-Based will entail individual work streams and deliverables.Transformative change in the integration of informatics and health IT in the delivery of health care requires attention to three areas: transforming the healthcare team experience, increasing patient engagement and satisfaction, and addressing population-based aspects of care. Each of these areas: Team, Patient, and Population-Based will entail individual work streams and deliverables.

22. 2. CREATE A HEALTH MANAGEMENT PLATFORM TO TRANSFORM PATIENT CARE Create a TEAM-facing Health Management Platform Prototype agile, iterative software development Technical solution - AViVA Migration Plan from CPRS AViVA Software Development Kit (SDK) 22 This project creates the platform for browser-based, clinical user-interface modules that are healthcare team-driven and enable elegant functionality which decrease cognitive load, effectively manage relationships between conditions, interventions and observations, acquire data (including documentation) as a by-product of workflow and ultimately support higher quality, safe patient care and clinician satisfaction. Some specific project elements are listed on the slide. The foundation for the Health Management Platform is AViVA, which we will discuss in more detail momentarily. The AViVA Software Development Kit (SDK) will allow other development teams to contribute and serves as a basis for moving toward an open-source environment.This project creates the platform for browser-based, clinical user-interface modules that are healthcare team-driven and enable elegant functionality which decrease cognitive load, effectively manage relationships between conditions, interventions and observations, acquire data (including documentation) as a by-product of workflow and ultimately support higher quality, safe patient care and clinician satisfaction. Some specific project elements are listed on the slide. The foundation for the Health Management Platform is AViVA, which we will discuss in more detail momentarily.

23. WHAT IS AViVA? Web-based, modular, standards-based IT architecture and modules that support: Comprehensive, integrated coded data Team-based, multi-patient care Workflow-driven, role-based activities Knowledge-driven, context-based decision support Open Source/open architecture environment Offers many benefits Agile, scalable, portable, extensible, reusable Robust and friendly user interface 23 The vision guiding AViVA includes three key components. The first component supports a major VA transformation in how care is provided from one patient and one clinician at a time to care provided in a team setting centered around and including the patient. The second component addresses the technical pathway for achieving interoperability and meeting the needs of the future while building on existing VA assets. The final component enables VA and the VistA community to benefit from the broad contributions and transparency of open source development. The vision guiding AViVA includes three key components. The first component supports a major VA transformation in how care is provided from one patient and one clinician at a time to care provided in a team setting centered around and including the patient. The second component addresses the technical pathway for achieving interoperability and meeting the needs of the future while building on existing VA assets. The final component enables VA and the VistA community to benefit from the broad contributions and transparency of open source development.

24. ARCHITECTURAL MIGRATION This is a high-level graphical representation of what the migration to AViVA may look like. The key points highlighted on the right are: At the top or presentation layer, where end-users interact with the clinical information systems is the issue of a single executable. This has numerous drawbacks such as slow releases, having to deploy fixes to 128 VistA systems and limited display capabilities. With AViVA, the solution is modules hosted in a web browser, which facilitates faster release cycles and meaningful display of information. In the middle tier or Business Logic Layer, where now we have VistA Packages, we have the problems of tightly coupled, inaccessible business logic and proprietary database schemas. Our current system is monolithic, not modular, nor component based. With migration to AViVA we decouple the logic and allow web service access that is standards �based. This gives us a scalable and reusable foundation promoting agility and innovation. In the bottom tier or Data layer, we currently have VistA FileMan data that is local VA centric. Information is location-based rather than patient-based. AViVA will support interoperable enterprise data not only from within VA, but from our partners in DoD and the health care community. This is a high-level graphical representation of what the migration to AViVA may look like. The key points highlighted on the right are: At the top or presentation layer, where end-users interact with the clinical information systems is the issue of a single executable. This has numerous drawbacks such as slow releases, having to deploy fixes to 128 VistA systems and limited display capabilities. With AViVA, the solution is modules hosted in a web browser, which facilitates faster release cycles and meaningful display of information. In the middle tier or Business Logic Layer, where now we have VistA Packages, we have the problems of tightly coupled, inaccessible business logic and proprietary database schemas. Our current system is monolithic, not modular, nor component based. With migration to AViVA we decouple the logic and allow web service access that is standards �based. This gives us a scalable and reusable foundation promoting agility and innovation. In the bottom tier or Data layer, we currently have VistA FileMan data that is local VA centric. Information is location-based rather than patient-based. AViVA will support interoperable enterprise data not only from within VA, but from our partners in DoD and the health care community.

25. CLINICAL WORKFLOW 25 Moving from architecture to our Clinical Information Systems, specifically our Computerized Patient Record System. This slide depicts the clinical workflow of Assess, Plan, Do and Evaluate. Briefly, the high level clinical workflow is to: Assess the status of the patient, why is the patient being seen, what�s the patient�s history, what is new, determine health risks, and address health promotion and disease prevention Plan interventions and establish goals of care Do the interventions and execute the plan of care Evaluate the intervention outcomes, and the goals of care and Begin the cycle again In the current model, CPRS, our primary clinical software supports mostly the �Do� actions. For example, ordering, signing notes, and receiving notifications, but it offers little in the way of supporting other parts of the clinical workflow. There is some limited support for assessments by way of templates and health summaries, but overall, CPRS is provider or professional centric and doesn�t support active collaboration among the entire care team throughout the workflow. The new model requires our clinical software to support Patient-Centric/Team-Based care. In this model patient preference, patient engagement and shared decision-making is present throughout the workflow and software must support the collaboration, communication and action among the entire team which now includes the patient. Moving from architecture to our Clinical Information Systems, specifically our Computerized Patient Record System. This slide depicts the clinical workflow of Assess, Plan, Do and Evaluate. Briefly, the high level clinical workflow is to: Assess the status of the patient, why is the patient being seen, what�s the patient�s history, what is new, determine health risks, and address health promotion and disease prevention Plan interventions and establish goals of care Do the interventions and execute the plan of care Evaluate the intervention outcomes, and the goals of care and Begin the cycle again In the current model, CPRS, our primary clinical software supports mostly the �Do� actions. For example, ordering, signing notes, and receiving notifications, but it offers little in the way of supporting other parts of the clinical workflow. There is some limited support for assessments by way of templates and health summaries, but overall, CPRS is provider or professional centric and doesn�t support active collaboration among the entire care team throughout the workflow. The new model requires our clinical software to support Patient-Centric/Team-Based care. In this model patient preference, patient engagement and shared decision-making is present throughout the workflow and software must support the collaboration, communication and action among the entire team which now includes the patient.

26. FROM CHART TO HEALTH MANAGEMENT PLATFORM 26 AViVA will allow us to move in the next stage of development from CPRS, CPRS replicated paper chart elements and added features such as computerized order entry, order and allergy checking, templates, notifications and clinical reminders. CPRS made the medical record legible, available at all times and a driver for evidence based medicine. However, sustained development of CPRS cannot adequately address the evolving and increasingly demanding health care needs. In the transformation, CPRS will migrate from an electronic chart to a knowledge-driven Health Management Platform that encompasses the cognitive workflow - involving informaticians, human factors experts, cognitive, social and process engineers in future product development. AViVA will allow us to move in the next stage of development from CPRS, CPRS replicated paper chart elements and added features such as computerized order entry, order and allergy checking, templates, notifications and clinical reminders. CPRS made the medical record legible, available at all times and a driver for evidence based medicine. However, sustained development of CPRS cannot adequately address the evolving and increasingly demanding health care needs. In the transformation, CPRS will migrate from an electronic chart to a knowledge-driven Health Management Platform that encompasses the cognitive workflow - involving informaticians, human factors experts, cognitive, social and process engineers in future product development.

27. Create a PATIENT-Facing Health Management Platform Analyze existing patient-facing systems - Identify overlap, gaps, and potential for creating common functionality used by all systems Define a roadmap for expanding patient-facing IT solutions 2. CREATE A HEALTH MANAGEMENT PLATFORM TO TRANSFORM PATIENT CARE 27 The 2nd focus area of creating a transformational Health Management Platform is the Patient-Facing Platform. This project provides strategic planning, alignments and a platform to create solutions that achieve meaningful patient use, population reach and impact. The Initiative embraces Participatory Medicine, a cooperative model of health care that encourages and expects active involvement by all connected parties (patients, caregivers, healthcare professionals, etc.) as integral to the full continuum of care. Or in the words of the Society for Participatory Medicine: Participatory Medicine is a movement in which networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners. This project will provide the informatics platform to enable our Veteran patients as full partners.The 2nd focus area of creating a transformational Health Management Platform is the Patient-Facing Platform. This project provides strategic planning, alignments and a platform to create solutions that achieve meaningful patient use, population reach and impact. The Initiative embraces Participatory Medicine, a cooperative model of health care that encourages and expects active involvement by all connected parties (patients, caregivers, healthcare professionals, etc.) as integral to the full continuum of care. Or in the words of the Society for Participatory Medicine: Participatory Medicine is a movement in which networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners. This project will provide the informatics platform to enable our Veteran patients as full partners.

28. 3. BUILD HEALTH INFORMATICS CAPACITIES������� 28 The Health Informatics Initiative is not focused solely on clinical software enhancements or evolution of IT, but also on strengthening VA�s informatics capacity and the relationship of health IT to clinical initiatives. These projects establish the framework necessary to create sustainable capacity to support healthcare modernization and improved care delivery through health informatics. This project will address inconsistencies in the VA�s educational preparation of informatics staff, informatics training resources and training options. Health informatics is a long-standing and traditionally informal component of VHA business/clinical practice. The result is that the impact of clinical informatics varies considerably from site to site. It will define collaboration and communication methodologies to ensure health informatics issues affecting the delivery of care are uniformly addressed across the enterprise. It will also provide organizational consistency in Health Informatics practices. It will facilitate Health Informaticist career establishment, development and retention in the VA. The Health Informatics Initiative is not focused solely on clinical software enhancements or evolution of IT, but also on strengthening VA�s informatics capacity and the relationship of health IT to clinical initiatives. These projects establish the framework necessary to create sustainable capacity to support healthcare modernization and improved care delivery through health informatics. This project will address inconsistencies in the VA�s educational preparation of informatics staff, informatics training resources and training options. Health informatics is a long-standing and traditionally informal component of VHA business/clinical practice. The result is that the impact of clinical informatics varies considerably from site to site. It will define collaboration and communication methodologies to ensure health informatics issues affecting the delivery of care are uniformly addressed across the enterprise. It will also provide organizational consistency in Health Informatics practices. It will facilitate Health Informaticist career establishment, development and retention in the VA.

29. INITIATIVE 16 SUMMARY Evolve CPRS into Health Management Platforms that transform the way teams deliver care, but incorporate meaningful patient involvement and population health Pilot agile and iterative development and requirements methodologies that re-introduce clinician iterative collaboration to speed delivery of IT modules Build VA�s health informatics capacity to support healthcare modernization and improved care delivery through informatics.� Partnering with VA�s clinicians, nurses, CACs, Pharmacists and other health professionals, VA�s health informaticists will build the knowledge infrastructure to support and drive the Health Management Platforms � transforming VA�s healthcare delivery 29 Initiative 16 is essentially about 3 things. The Health Informatics initiative supports VA�s core values of caring for its patients and its staff. We value the health and well-being of our patients, and strive to maximize their quality of life and level of function. We value the work and commitment of our healthcare teams of all types, and strive to optimize their effectiveness, efficiency, and satisfaction with their work. In the larger context, we value the quest for knowledge that contributes to improving the care of our patients and the daily life of our healthcare teams. We must consider the needs of our patients as we would consider our own in the same circumstances. We would all like healthcare teams that have the tools to do their best job for us; health care informed by shared knowledge of diagnostic studies, diagnoses made, and treatments delivered across sources of care; tools for engaging in our own health care, managing our personal health record, and communicating with our healthcare teams in a safe and convenient way; a health care system that is able to devote the right kind and the right amount of resources to our care; health care technology that leads the nation and takes advantage of both VA and non-VA expertise. Initiative 16 is essentially about 3 things. The Health Informatics initiative supports VA�s core values of caring for its patients and its staff. We value the health and well-being of our patients, and strive to maximize their quality of life and level of function. We value the work and commitment of our healthcare teams of all types, and strive to optimize their effectiveness, efficiency, and satisfaction with their work. In the larger context, we value the quest for knowledge that contributes to improving the care of our patients and the daily life of our healthcare teams. We must consider the needs of our patients as we would consider our own in the same circumstances. We would all like healthcare teams that have the tools to do their best job for us; health care informed by shared knowledge of diagnostic studies, diagnoses made, and treatments delivered across sources of care; tools for engaging in our own health care, managing our personal health record, and communicating with our healthcare teams in a safe and convenient way; a health care system that is able to devote the right kind and the right amount of resources to our care; health care technology that leads the nation and takes advantage of both VA and non-VA expertise.

30. QUESTIONS 30