Veterans Health Administration

1. Management using Health Information System George Mason UniversityDecember 1, 2006Syed Tirmizi, MDMedical InformaticianVeterans Health Administration

2. Veterans Health Administration • 5.3 million patients, ~ 7.7 million enrollees • ~ $30 Billion budget • 1,400 Sites-of-Care • 198,500 Employees (~14,500 MD , 58,000 Nurses, 33,000 AHP) • Affiliations with 107 Academic Health Systems • $1.7B Research: Rehabilitation, Health Services, Clinical, Basic

3. Who Are VA Patients ? • Older • 49% over age 65 • Sicker • Compared to Age-Matched Americans • 3 Additional Non-Mental Health Diagnoses • 1 Additional Mental Health Diagnosis • Poorer ~ 70% with annual incomes < $26,000 ~ 40% with annual incomes < $16,000 • Changing Demographics • 7.0% female overall • Females: 22.5% of outpatients less than 50 years of age

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

5. VA’s Health Information System ….VistA • “CPRS” is the integrated EHR application • VA runs 128 VistA systems • Down from 172 VistA systems 10 years ago • Delivers a complete hospital information system, electronic health record, imaging, Bar Code Medication Administration • Hardware, software, maintenance, upgrades, staffing • For FY2004: • Cost per enrollee • $78 / enrollee • Average cost per hospital (n=158) • $3.6 million

6. Electronic Health Records &Computerized Provider Order Entry • Computerized Provider Order Entry (CPOE) is one of the Leapfrog Group’s “Top 3 Safety Strategies” • Outside of VA, CPOE < 15% nationally • < 30% among Academic Medical Centers • Nationally, 94% of all VA prescriptions are entered directly by providers • Ultimate Goal: 100% • VA is the Benchmark for CPOE

7. Uses a Chart Metaphor - Combining Text and Images • Single longitudinal health record is immediately available in • Outpatient • Inpatient & • Long-term care settings

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

13. Informatics Support for Clinical Practice Guideline Implementation • Pathman, et al. Medical Care 1996; 34:873-889

14. Bar-Code Medication Administration (BCMA) BCMA Assures: Right Medication Right Dose Right Patient Right Provider Right Time Virtually Eliminates Errors at the Point of Administration . . . Coming Soon: Bar-Coded Lab Specimen, Blood Administration, & more

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

16. How Do We Compare to non-VA Providers?VHA Continues to exceed HEDIS in the vast majority of 17 common measures HEDIS = Health Plan Employer Data & Information Set From the National Committee on Quality Assurance (NCQA)

17. How Do We Compare to non-VA Providers?VHA Continues to exceed HEDIS in the vast majority of 17 common measures

18. Amputations per 1000 patients FY99-04 Changes in Total, Major and Minor Age-Adjusted Amputation Rates Among Patients With Diabetes

19. Vaccine Cuts Pneumonia Risk in High-Risk Patients* • 50% of elderly Americans / high-risk individuals have not received the pneumococcal vaccine. • VA Medical Center study of 1,900 elderly patients with chronic lung disease; 2/3 vaccinated against pneumonia. • Pneumococcal vaccination: • 43% reduction in hospitalizations for pneumonia and influenza, and a 29% reduction in the risk of death. • Pneumonia and Influenza vaccination: • 72% reduction in hospitalizations for these two diseases and an 82% reduction in deaths from all causes. • Pneumococcal vaccination saved an average of $294 per vaccine recipient over the 2-year period. *Archives of Internal Medicine 1999;159:2437-2442Dr. Kristin Nichol, VAMC / Minneapolis

20. Pneumococcal Vaccination Rates in VHA --BRFSS 90th-- --BRFSS-- • Iowa: Petersen, Med Care 1999;37:502-9. >65/ch dz • HHS: National Health Interview Survey, >64

21. 50% 40% 30% 20% 10% 0% -10% -20% 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 - -0.3% 0.8% -6.2% -8.6% -6.5% -7.3% -9.1% -4.6% 0.8% VHA Cost Per Patient 6.4% 14.9% 14.9% 12.8% 14.9% 25.5% 31.9% 40.4% 44.7% Avg. Medicare Payment/Enrollee - 3.3% 5.9% 9.8% 13.5% 18.4% 23.7% 29.5% 34.7% 39.4% Medical CPI VHA Cost Per Patient Avg. Medicare Payment/Enrollee Medical CPI Ten Year Cumulative Percent Change in Costs - VA, Medicare, CPI • VHA Cost per Patient– Total Medical Care Obligations per Total Unique Patients (including non Veterans) • Average Medicare Payment per Enrollee—Medicare Program Benefits per Enrollee (www.cms.hhs.gov/researchers/pubs/datacompendium) • Medical Consumer Price Index--Bureau of Labor Statistics (household “out of pocket” medical expenses including insurance and co-payments)

22. Over 16,000 veterans now using home telehealth devices Home Telehealth Technologies

23. PHRPersonal Health Record

24. Research – Harris Interactive • Two in five adults in the US keep their own personal and family health records. • 13% keep them electronically • 40% planning to do so in the future • More women (45%) than men (38%) kept records. • 58% of the over-65s filed information about their treatment. • 84% of all surveyed welcomed the Personal Health Record (PHR) concept. • Out of the 13% in the Harris survey who kept electronic records, only one in thirteen kept them online at a health record website. Source: Harris Interactive, August 2004 24

25. What Do Patients Value in a PHR? Angst, C. M., & Agarwal, R. (2004) “Patients Take Control: Individual Empowerment with Personal Health Records,” Center for Health Information and Decision Systems.

26. Predictors of PHR Use or Desire for Use • Convenience is a strong predictor of desire for PHR1 • Compliance is a predictor of PHR use2 • Connectedness is a predictor of PHR use2 • Age and Chronic Illness were not predictors but Education and Knowledge of PHRs were predictors of desire for PHR3 • 1Angst, C. M., & Agarwal, R. (Working Paper). “Getting Personal About Electronic Health Records: Modeling the beliefs of personal health record users and non-users,” • 2Agarwal, R., & Angst, C. M. (2006). “Technology-Enabled Transformations in U.S. Health Care: Early Findings on Personal Health Records and Individual Use,” In D. Galletta & P. Zhang (Eds.), Human-Computer Interaction and Management Information Systems: Applications (Vol. 5). Armonk, NY: M.E. Sharpe, Inc. • 3Angst, C.M., Agarwal, R., & Downing, J. (Working Paper). “An Empirical Examination of the Importance of Defining the PHR for Research and for Practice,” Under Review. 26

27. How comfortable would you be if an PHR was provided, sponsored, and/or maintained by: 27

28. The Chronic Disease Care Model Community HealthSystem Resources and Policies Organization of Health Care Self-Management Support VistA DeliverySystem Design Decision Support Productive Interactions Informed, Empowered Patient and Family Prepared, Proactive Practice Team My HealtheVet Improved Outcomes

29. What do people with Chronic Disease need? • A continuous healing relationship. • Regular assessments of how they are doing. • Effective clinical management. • Information and on-going support for self-management. • Shared care plan. • Active, sustained follow-up. * Ed Wagner – presentation “Beyond the Basics: Another Look at the Care Model”

30. Benefits to Providers • Transfer the “ownership” of chronic disease management to the patient. • Offers more complete picture of patient’s health conditions and health care, including non-VA care. • Reallocation of time in practice to more complex cases. • Ability to communicate and collaborate with patients more easily. • A study by McKay et al* found that patients who participated in an online diabetes education and support group lowered their blood glucose levels significantly more than controls did. *McKay HG, King D, Eakin EG, Seeley JR, Glasgow RE. The diabetes network Internet-based physical activity intervention: randomized pilot study. Diabetes Care 2001 Aug;24(8):1328-1334.

31. Benefits to VHA • One single touch point to reach entire veteran population. • Broadcast health bulletins (e.g., SARS, flu shot). • Interactive outreach to veterans for health education, VA specific programs, opportunities to participate in research programs, etc. • Enhanced patient satisfaction.

32. It’s all about the veteran…… • What does person-centric care look like? • Care where the patient is the focus of control. • Care that integrates across environments. • Care that integrates across health & disease. • Care that anticipates needs rather than just reacts to it. • Care that works with the patient in non-traditional environments.

33. 2006 Innovations in American Government Award Winner Visit www.innovations.va.gov

34. VA ‘s Use of Health IT Technology “[VA has] adopted aculture of patient safety and qualitythat is pervasive," says Karen Davis, president of Commonwealth Fund, which studies health-care issues.The centerpiece of that culture is VistA, the VA's much praised electronic medical-records system. … VistA has also turned out bea powerful force for quality control.” Business Week July 17, 2006

35. “ . . . Overall, VHA patients receive better care than patients in other settings” Articles About VA’s Info Technology & Quality “In summary, electronic health records, performance management, and a patient-centric focus have been critical transformational strategies for the VA. They have been utilized to support achievement and are associated with measurable progress in each of the VA’s value domains.” The American Journal of Managed Care, November 2004 “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)” Annals of Internal Medicine, December 21, 2004 Annals of Internal Medicine, August 17, 2004

36. VA ‘s Use of Health IT Technology “Veterans’ hospitals used to be a byword for second-rate care or worse. Now they’re national leaders in efficiency and quality. What cured them? A large dose of technology.” Fortune May 15, 2006

37. Recent Praise for VistA… “Despite my private sector credentials and experience, it is my duty to tell you that the current, comprehensive electronic health environment of the Veterans Health Administration surpasses any capability available today on the planet, whether in the private sector, other departments of the U.S. government, or the highly profiled activities of other countries.” Jonathan C. Javitt, M.D., M.P.H.(former Co-Chair, Health Care Delivery and IT Subcommittee, President’s Information Technology Advisory Committee) Testimony before the House Committee on Veterans’ Affairs, Subcommittee on Oversight and Investigations September 28, 2005

38. VistA’s Contribution to the High Quality Care Provided By VA The “culture of quality” depended on the successful implementation of several innovations:a uniform data collection system facilitated by nationwide implementation of an electronic medical record system, systematic application of quality standards, and externally monitored local area networks to monitor quality.” Annals of Internal Medicine, Editorial, August 17, 2004

39. Highest Quality of Care For Patients with Diabetes in VA “Diabetes processes of care and 2 of 3 intermediate outcomes were better for patients in the VA system than for patients in commercial managed care.” Annals of Internal Medicine, August 17, 2004

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

41. (Still More) Praise . . . “The Electronic Health Record in the Department of Veterans Affairs is the best in the United States, absolutely the best at large scale, and probably the best in the world.” John Glaser, Ph.D., October 2003Vice President & CIOPartners (Harvard) HealthCare System

42. Success In Supporting Health Care Delivery For Millions Of Veterans • VistA is a success • Built by “fire” of VHA collaboration • Publicly owned by VA • 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 • Initial system (1983-1996) was built around “dumb terminals” • “Decentralized Hospital Computer Program (DHCP)” • Steady deployment of packages and enhancements • Applications separated out by Hospital/Clinic “Service” • Simple “roll-and-scroll” screens

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

44. Information Exchange

45. DoD/VA InteroperabilitySolution Suite DoD VA One-way, enterprise exchange of text data FHIE FHIE BHIE Bidirectional, real-time exchange of text data BHIE Bidirectional, real-time, enterprise exchange of computable data CHDR CHDR

46. American Health Information Community (AHIC) • On September 13, 2005, Department of Health and Human Services announced the creation of American Health Information Community (AHIC). • formed to help advance efforts to reach President Bush’s call for most Americans to have electronic health records within ten years. • federally-chartered commission and will provide input and recommendations to HHS on how to make health records digital and interoperable, and assure that the privacy and security of those records are protected, in a smooth, market-led way. More Info: http://www.hhs.gov/healthit/ahic.html

47. Health Care Industry Compliance Certification NHIN Privacy / Security Biosurveillance Consumer Empowerment Chronic Care Electronic Health Records Breakthroughs Standards Harmonization Coordination of Policies, Resources, and Priorities Office of the National Coordinator -Health IT Policy Council-Federal Health Arch. The Community -Workgroups Technology Industry Industry Transformation Infrastructure Health IT Adoption January 17, 2006 Consumer Value Health Information Technology Deployment Coordination

48. CLINICAL PATIENT RECORD VISTA SOFTWARE PACKAGES VOLUNTARY SERVICE REHAB MEDICINE ACCOUNTS RECEIVABLE MEDICAL LIBRARY Vista IMAGING RECORDS NURSING TRACKING ADMISSION DISCHARGE TRANSFER INTEGRATED DATABASE RADIOLOGY PERSONS PATIENT FUNDS BLOOD BANK PATIENTS PROBLEM LIST DRUGS RPC BROKER SOCIAL WORK MAILMAN LABORATORY MENTAL HEALTH DEVICE COMPUTERIZED PATIENT RECORD SYSTEM (CPRS) TASK MANAGER WARDS KERNEL MANAGER LAB RESULTS DENTAL ENGINEERING MENU MANAGER USER SECURITY SURGERY VA FILEMAN ONCOLOGY HEALTH SUMMARY BAR CODE MEDICATION ADMINISTRATION PRESCRIPTIONS INVENTORY DIETETICS INPATIENT PHARMACY IMAGES TEXT INTEGRATION UTILITIES(TIU) MEDICINE WOMEN’S HEALTH OUTPATIENT PHARMACY INTEGRATED FUNDS CONTROL ACCOUNTING & PROCUREMENT SCHEDULING MEDICAL CARE COST RECOVERY CONSULTS / RESULT TRACKING VISTA INFORMATION SYSTEM AUTHORIZATION SUBSCRIPTION UTILITY (ASU) CLINICAL REMINDERS

50. Sharing VA’s Expertise • Consolidated Health Informatics (CHI) • Federal interagency initiative; VA a founding partner • Endorsed 20 data & communication standards to date • VistA-Office EHR (VOE) • Collaboration with Dept. of Health & Human Services to foster wider adoption of EHRs • Based on VistA/CPRS, configured for physician office/clinic settings • Beta version released by HHS for evaluation • American Health Information Community (AHIC) • Public-private collaboration to develop standards and increase interoperability of health information • Certification Commission for Healthcare Information Technology (CCHIT)