VHA-IHS Collaboration: History and Current Initiatives

1. VHA-IHS Collaboration:History and Current Initiatives Background for VA-IHS CIO meeting Clayton Curtis MD PhD VHA-IHS Interagency Liaison & Informatics 857-364-4786 August 25, 2010

2. Presentation topics • VHA-IHS background and challenges • HealtheVet migration and impact on IHS • Opportunities and current VHA-IHS initiatives

3. IHS “at a glance”

4. Government-to-government relationship between the federal government and the Indian tribes Relationship was established in 1787 and based on Article I, Section 8 of the Constitution IHS is the principal health care provider and health advocate for Indian people IHS background information Eligibility for care is based on tribal membership, patients includes women and children.

5. IHS background information • The Indian Self-Determination and Education Assistance Act provides tribes with the option of assuming the administration and operation of health programs within their communities or of remaining within the IHS administered direct health system. This is a real kicker, and accounts for what looks like organizational disorganization.

6. IHS mission and goal Our Mission... to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level. Our Goal... to assure that comprehensive, culturally acceptable personal and public health services are available and accessible to American Indian and Alaska Native people. Very similar to VA philosophically.

7. IHS health care delivery system • IHS currently provides health services to approximately 1.6 million American Indians and Alaska Natives from over 560 federally recognized tribes in 35 states. • The federal system consists of 36 hospitals, 61 health centers, 49 health stations, and 5 residential treatment centers. In addition, 34 urban Indian health projects provide a variety of health and referral services. IHS is not a small healthcare system, though facilities are smaller.

8. IHS health care delivery system IHS “Area” = VA “VISN” IHS is highly rural, mostly in Western states.

9. What IHS does • Provide comprehensive health care services: hospital & ambulatory medical care, preventive & rehabilitative services, and development of community sanitation facilities. • Serve as the principal Federal advocate in the health field to ensure comprehensive health services for American Indian and Alaska Native people. A broad functional spectrum…

10. Health care delivery • Preventive measures involving environmental, educational, and outreach activities are combined with therapeutic measures into a single national health system. • Special initiatives in traditional medicine, elder care, women's health, children and adolescents, injury prevention, domestic violence and child abuse, health care financing, state health care, sanitation facilities, and oral health …VERY broad!

11. VHA and IHS

12. What relates VHA and IHS in clinical computing? • VHA and IHS have a 25+ year partnership in large-scale clinical computing; VHA’s technology was adopted by IHS in 1984, and the first MOU was negotiated in 1986 • VHA and IHS have large “health care chain” deployments of a comprehensive clinical information system • VHA and IHS have accumulated LOTS of “school of hard knocks” experience • VHA and IHS are both influenced by Federal initiatives including FHA, ONC, and GWOT We’re in the same boat. We do more TECHNOLOGY sharing with IHS than with DoD

13. What has happened over time? • RPMS began as an offshoot of DHCP in 1984 • IHS developed major enhancements in outpatient and longitudinal records, many of which have migrated to VHA • VHA and IHS have both undergone major organizational change (VHA: integrated service delivery networks; IHS: tribal compacting and program expansion) • VHA and IHS have slowly diverged due to different priorities and interests; that has impacted IHS ability to absorb new releases of VHA packages and leverage VHA investment We are probably missing some opportunities to take advantage of each other’s work.

14. Where are we now? • IHS has identified migration to electronic records and closer approximation to core VistA packages as major initiatives • IHS has migrated to a component-based GUI framework for electronic records (ViewCentric / EHR – 180 live sites); VistA has no similar plans since the demise of HealtheVet Desktop • VHA and IHS staff work to keep EHR pilot sites (and, eventually) all sites in synch with current releases of core VHA packages • VHA has undertaken a major change in the technology base for VistA, and re-engineering of major applications (HealtheVet VistA) We are both at critical junctures in our evolution.

15. Challenges for VA/VHA … • Figure out the relationship with IHS and OI&T in the post-reorganization world • Figure out how to work with IHS on “legacy” VistA / RPMS applications in the M environment • Determine whether / where IHS innovations can be leveraged by VHA • Facilitate IHS use of packages that complement CPRS/EHR, such as VistA Imaging and Care Management

16. Challenges for IHS … • Deploy current versions of “current VistA” applications in the M environment • Break through barriers to moving to recent versions – e.g., code set versioning • Develop architecture, implementation, and support models for packages that complement CPRS/EHR, such as VistA Imaging and iMED Consent • Understand and evaluate the potential for IHS migration to VHA’s new platform and application architecture

17. Infrastructure Master Patient Index Health Data Repository Administrative Data Repository Interface Engines Clinician applications CPRS enhancements Imaging Remote data views Interfacility consults Patient applications My HealtheVet Other impacts Shift of core packages to COTS (e.g., Lab) Shift in architecture (e.g., centralized scheduling) Shift to regional data processing centers Things for IHS to consider…

18. Things for VA/VHA to consider… • Infrastructure • Enhanced Kernel Broker (reliability, event notification) • Clinician applications • Integrated case management (iCARE) • Women’s Health • Other applications • National performance measure system (CRS) VHA Office of Quality & Performance is asking IHS for assistance with designing and migrating to an electronic replacement for EPRP. IHS is NOT “just running DHCP/VistA”

19. Opportunities for IHS and VA/VHA to work together on clinical information systems

20. VA/VHA Evolution – IHS impact • Evolution of package functionality • CPRS • VistA Imaging • BCMA • iMED consent • Migration to new technology foundations • Java and relational database • Component framework for GUI applications (TBD) • Introduction of major architecture elements • Health Data Repository (HDR) • Master Patient Index (MPI) • Interface engines

21. Opportunities for partnership • Convergence on core packages (e.g., Pharmacy, Lab, Radiology) • Joint participation in requirements definition • Incorporation of IHS functional requirements into core VistA and VistA Office EHR • Sharing of IHS changes made for VOE and CCHIT certification to enhance VistA • Migration to shared component-based GUI framework • Continued development of IHS-specific applications in new technical framework

22. Challenges for interagency work • Absence of a direct OI&T-IHS relationship • Side effect of reorganization of VA IT • VA mis-perception of relationship as being primarily with VHA • Mutual skepticism • “IHS is a fly on the wall” • “VA IT and VHA have no real interest in collaboration” • Absence of policy on collaboration • “Who is IHS and why should we work with them?” • “Is it ok to share [something] with IHS?” • Absence of business ownership of joint interagency activities. • Absence of equivalent of DoD-related structures such as HEC/JEC, IM/IT WG, HAIG, etc.

23. Current initiatives • Package coordination and “discovery” • Funded support by OI&T for IHS VistA Imaging planning and implementation at selected EHR sites (>45 sites in multiple IHS Areas) • Execution of Inter-Agency Agreement (IAA) for funding of VA support to the IHS implementation of VistA Imaging [in VA Contracting / OGC] • Pilot of CMOP services to IHS [in operation at Rapid City] • Operation of the VA-IHS VPN tunnel. [Vehicle for interagency communication]

24. Possible / pending initiatives • Incorporation in VistA of IHS-developed enhancements to CPRS/VistA • Women’s Health re-engineering and iCare • CCHIT (EHR certification in general) • e-prescribing • Component-based GUI framework • …?

25. Health IT Sharing Coordination

26. Current initiatives • Portal site supporting collaboration activities (IHS hosted)http://vhacollaboration.ihs.gov/ • Requires user account, easily obtained • VA-VHA-IHS Health IT Sharing coordination group (self-chartered, to date) • Representatives from VA OI&T, VHA, IHS • April 2009 face-to-face meeting • HIT coordination action item list on collaboration server • Tracked projects list on collaboration server

27. http://vhacollaboration.ihs.gov

28. http://vhacollaboration.ihs.gov

29. Opportunities for IHS and VHA to Share Data

30. Policy Related to Data Sharing • Umbrella DVA/VHA – HHS/IHS MOU • 2003 agreement still in force, considered valid • Encourages general sharing, mentions IT and data • HIPAA provisions already exist for patient care or for coordination of care, quality • VHA Privacy Officer will be issuing guidance via Privacy Letter • Templates for common scenarios will be developed • VHA Directive on Interdepartmental Coordination • Remains in in concurrence • No detailed mention of IT or data sharing, but implied

31. Factors in Data Sharing • 7332-protected information (MH, alcohol / drug abuse treatment, etc.) is a major barrier to sharing patient data at point of care • Can’t absolutely prevent inadvertent release because no way to filter free text absolutely and other data may indirectly convey information • No legislative exemption as with VA-DoD • VA policy requires agreement on security and uses of data (“Data Use Agreement”) • Major reason for local MOU • Some good examples of MOUs exist • VISN 16 and VISN 18 • Templates for common scenarios should be available Fall 08

32. Options For Clinical Data Access at the Point of Care • Data sharing via National Health Information Network • Federal demonstration 9/08, production (limited data sets) 12/08; active pilots (2009-2010) • Data sharing via CPRS and VPN • Requires VA VPN (RESCUE, etc.), VA network account, installation of CPRS client • IHS access to VistA data via VistA Web (currently unidirectional) and local project MOU • Technically feasible today • Pilot died due to patient consenting requirement

33. Questions?