The Future of Health Information Technology Health e People: IHS & VHA Moving Forward Together

1. The Future of Health Information Technology  HealthePeople:IHS & VHAMoving Forward Together August 24, 2004IHS Information Technology Conference Robert M. Kolodner, MDActing Chief Health Informatics Officer &Acting Deputy CIO for Health Veterans Health Administration Department of Veterans Affairs

2. Outline • VA/VHA – Do you know what’s been going on? • Electronic Health Records EHR in VA (VHA) • VistA – current status • Benefits to patient care • HealtheVet – the Next Generation VistA • Why Change? • What will HealtheVet-VistA look like? • Standards & Personal Health Records • Brief highlights • HealthePeople • Plans for IHS & VHA to work together on IT • VHA’s commitment to HealthePeople and to IHS • Implications for IHS and potential IHS benefits IHS Technology Conference

3. Alternate Outline Current VistA HealtheVet-VistA HealthePeople-VistA What does all this mean for IHS? IHS Technology Conference

4. 2004: Who is “VA”?Veterans Health Administration • Locations & Affiliations ~ 1,300 Sites-of-Care • Including 158 medical centers, ~ 850 clinics, long-term care, domiciliaries, home-care programs • Affiliations with 107 Academic Health Systems • Additional 25,000 affiliated MD’s • Almost 80,000 trainees each year • 60% (70% MDs) US health professionals have some training in VA IHS Technology Conference

5. 2004: Who is “VA”?Veterans Health Administration • Budget, Staff, & Patients ~193,000 Employees (~15,000 Doctors, 56,000 Nurses, 33,000 AHP) • 6% decrease since 1995 • 13,000 fewer employees than 1995 ~ $27.4 Billion budget • 42% increase since 1995 • Flat at ~ $19B from 1995 - 1999 • 5.1 million patients, ~ 7.5 million enrollees • 104% increase in patients treated since 1995 • From 2.5 million patients / enrollees in 1995 IHS Technology Conference

6. Changing Health Care Changing Workload in VA IHS Technology Conference

7. Toward a “Virtual Health System” • Electronic Health Records (EHRs) • Robust, Widespread Use of High Performance Electronic Health Records (EHRs) • Standards • Health Data & Communication Standards • Personal Health Records (PHRs) • Full copy of one’s own health information along with personalized services based on that information • Health Information Exchange • Connectivity Among the EHRs, PHRs, and related health entities IHS Technology Conference

8. EHRElectronic Health Record

9. DHCP  RPMS DHCP  RPMS & CHCS DHCP  RPMS & CHCS  VistA DHCP DecentralizedHospitalComputerProgram Resource andPatientManagementSystem CompositeHealthCareSystem IHS Technology Conference

10. 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)” “Using a digital medical record that follows veterans from one facility to another, the VHA has improved quality of care for patients while staying within a tight budget.” Wall Street Journal, July 15, 2002 IHS Technology Conference

11. Praise for VistA – from Users “…frustration and disenchantment were widespread …. Several well-known technology vendors were subjects of biting criticism by name. Satisfaction with systems (in some cases from the same vendors) tended to be expressed in less than gushing terms.” “But there was one notable outlier from the nexus of negativity; the Veterans Administration. It received unwavering praise….” • Summary of results from almost 1600 respondents to a survey of American College of Physician Executives members regarding their organizations’ progress in implementing clinical information systems • Most indicated that problems and ordeals continue The Physician Executive – March-April 2004 IHS Technology Conference

12. Electronic Health Records (EHR) &Computerized Provider Order Entry (CPOE) • 100 % VA Medical Centers have Electronic Health Record • CPOE is one of the Leapfrog Group’s “Top 3 Safety Strategies” • Outside of VA, CPOE < 8% nationally • < 30% among Academic Medical Centers • Nationally, 93% of all VA Rx’s by CPOE • Ultimate Goal: 100% • VA is the Benchmark for CPOE • All VA Medical Centers also have Desktop Imaging IHS Technology Conference

13. Some National VistA Statistics (Total / Daily) • Number of orders • 1.14 Billion / >860,000 • Number of Documents (Progress Notes, Discharge Summaries, Reports) • 533,000,000 / >510,000 • Number of Medications Administered with BCMA • 500,000,000 / >580,000 • Number of Images • 197,000,000 / ~340,000 IHS Technology Conference

14. Performance MeasurementSetting the U.S. Benchmark for 18 Comparable Indicators IHS Technology Conference

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17. Two-Way Exchange of IT Solutions Between IHS & VA • VistA contains solutions “borrowed” from IHS • Health Summary • Patient Care Encounter (PCE) from PCC • File Manager 17 • Patient Merge • Clinical Reminders (version 1) • And more IHS Technology Conference

18. In Summary • VistA/CPRS was & is a success • Built by “fire” of VHA collaboration • In the public domain; could be for future as well • Strong interest by public/private in using VistA • National software w/ local flexibility/innovation: • Innovation developed locally & enterprise wide • Standard packages distributed enterprise wide, e.g. latest version of CPRS IHS Technology Conference

19. VistA - Why change? • Not lose functionality we have • Strengthen VistA • Move to person & data focus • Move to standardized, fully sharable health data • Modernize & replace older systems • Ensure documentation on application programs • Move to modern technologies • Increase flexibility to respond to future health needs • Lower cost of maintenance • Support our future health system IHS Technology Conference

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21. Operational (Clinical) Drivers for Change • 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 and maximized function/health (time to zero) • Inconvenience (inconvenience to zero) IHS Technology Conference

22. HealtheVet – Strategy Overview • Moves from facility-centric to person/data-centric • Uses national, person-focused health data repository for production & management/analysis/research • Builds on, enhances & utilizes VistA • Moves from legacy VistA to HealtheVet-Vista • Uses best, appropriate modern technology • Programming, software, hardware, networking • Standardizes the “core” applications • Provides processes for local enhancements beyond the “core” • Standardizes data & communications IHS Technology Conference

23. What is HealtheVet-VistA ? HealtheVet-VistA is the next generation of the existing VistA Legacy systems achieved by incrementally rehosting or reengineering current health & administrative information applications to operate using modern technologies. Once HealtheVet-Vista is fully implemented, the VistA Legacy system will be retired. IHS Technology Conference

24. EHR – Beginning the Upgrade • 1st JAVA code released • HealtheVet Desktop • Care Management software (version 1) • Brand new type of functionality – in its infancy • “The baby needs time to grow” – VHA’s pattern of IT success over the past 20+ years • On the verge of last release of CPRS (!!!!) • Code finished now • Field release early in 2005 • To be replaced by CPRS-R (Rehost/Reengineer) • Begins migration from M(UMPS) & Delphi to JAVA & J2EE IHS Technology Conference

25. EHR – VA’s Next Leap ForwardCPRS-R • Scheduled for release in late Summer 2005 • Sets the stage for modular enhancements & computable data from the HDR • New look and feel (evolution, not a disruptive change) • View patient data from interim HDR (Remote Data View+) • Drug-Drug & Drug-Allergy order checks on remote data • Includes data from DoD • View remote images attached to remote notes • Initial rehosting with 4 follow-up phases • Clinical Documents • Orders Management • Clinical Decision Support • Integration with the local and national HDR IHS Technology Conference

26. EHR – VA’s Next Leap ForwardHDR • Health Data Repository (HDR) • Domain-by-domain uploading to the national HDR as local VistA data is “cleaned” to align with new standards • Standardized (and computable) data from all VHA sites • Data “cleaning” will go back only a limited number of years (may vary by domain) • Older “non-standardized” data resides in HDR Historical • Remains available • Text form is the same as current Remote Data Views data • 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) IHS Technology Conference

27. EHR – VA’s Next Leap ForwardHDR • 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 IHS Technology Conference

28. New Software Relational Database VERY Simple Schematic IHS Technology Conference

29. New Software Local Relational Database Relational Database VERY Simple Schematic IHS Technology Conference

30. New Software Local Relational Database Relational Database VERY Simple Schematic IHS Technology Conference

31. New Software Local Relational Database Relational Database VERY Simple Schematic IHS Technology Conference

32. New Software New Software Local Relational Database Local Relational Database Relational Database VERY Simple Schematic Hospital or Clinic IHS Technology Conference

33. VistA to HealtheVet (& HealtheVet-VistA) VistA Legacy (Maintenance/Enhancement until “Retirement”) [Current – 2005] .... 2000 2001 2002 2003 2004 2005 2006 2007 Enterprise Architecture Strong Project Management VistA Imaging Fee High Performance Network/Infrastructure Secure systems/infrastructure Billing Health Data Repository HealtheVet-VistA (Person/Data-Centric Next Generation VistA) (2005- ) Scheduling VA-wide OneVA activities High Performance Workforce VHA HealtheVet Activities Pharmacy Laboratory IHS Technology Conference

34. HealtheVet-VistA box and oval schematic InformationExchange PHR EHR Standards IHS Technology Conference

35. Principles Guiding HealtheVet-VistA • Commitment to remaining in the public domain for the “core” software – Open Source?? • Scheduling, Pharmacy, Laboratory • Management/financials used by VA may be all COTS • Support linkage with COTS specialty products (e.g., ICU & Anesthesia Systems) • Design maximizes vendor independence • JAVA/J2EE software to be use generic function, rather than proprietary extensions • Support for “relational databases” and not just one database vendor • Some estimates that ~20% of the software may use vendor (database) extensions for performance gains • Uses Common Services Architecture • Enhancements often possible by improving a component or service rather than re-writing an entire application IHS Technology Conference

36. Principles Guiding HealtheVet-VistA • Phased migration from VistA to HealtheVet-VistA • Do not move from existing software until replacement is “solid” without loss of existing functionality • “Core” modules are standardized and “locked down” • Innovation from extensions around the core • If “Open Source”, then opportunities for direct contributions by enhancing the core • Adheres to Federally-adopted data and communications standards IHS Technology Conference

37. Standards

38. Standards – Advances in the Federal Government • SNOMED: Played key role in license negotiations & purchase • SNOMED now available at no cost to every health organization in the US • CHI (Consolidated Health Informatics): Continued active leadership role – an eGov Initiative • Participants include VA, DoD, HHS, NIH, IHS, CDC, FDA • CHI has endorsed data and communication standards in 20 domains • Some recent domains: Anatomy, Demographics, Immunizations, Medications, Laboratory Test Order Names, Units • Adoption of the same standards by all CHI participants, including DoD and IHS • Beginning the implementation of these standards VA-wide IHS Technology Conference

39. PHRPersonal Health Record

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41. What Is MHV? • My HealtheVet • A new ehealth portal where veterans, family, and clinicians may come together to optimize veterans’ health care • Web technology • Will combine essential patient record information and online health resources to enable and encourage patient/clinician collaboration • Veterans • Will be provided with information on benefits, services, and special programs, and can request services online IHS Technology Conference

42. 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 IHS Technology Conference

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44. Improved health & “paperless” • Standards • Data • Communications • --------------------- • Health Info Systems • Electronic Health Records Systems (EHRs) • Personal Health Record Systems (PHRs) • Info Exchange Adoption by health organizations & persons of affordable, high quality & standards-based EHRs, PHRs & Health Info Exchange Improved Health Paperless (IOM) 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 * This graphic inspired by discussions at a Kaiser-Permanente and IOM sponsored meeting in October 2001. IHS Technology Conference

45. HealthePeople Initiative:Toward a “Virtual Health System” • EHRs – • Provide financial incentives • Strongly encourage private sector vendors to make available affordable, high quality, standards-based EHRs • Strongly encourage provider-based efforts like AAFP • Continue to improve HealthePeople-VistA & make available • Standards – • Consolidated Health Informatics as federal leadership • Strongly encourage public/private development/adoption of national standards • PHRs – • Strongly encourage public/private sector to work together to develop & make available PHRs for persons • EHR/PHR Info Exchange (IE) – • Strongly encourage public & private sector to work together to develop & make available national “exchange” solution IHS Technology Conference

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48. Standards EHR InformationExchange PHR IHS Technology Conference

49. Recent 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 – April 27, 2004 IHS Technology Conference

50. Support from VA Secretary Principi “Because VA’s medical IT advances are in the public domain, our broad spectrum of solutions to health care’s challenges—from patient safety to real-time long-distance delivery of vital records and images—can be shared immediately with our partners in the private sector. ” Secretary Principi – May 6, 2004 IHS Technology Conference