big data and vista evolution, theresa a. cullen, md, ms

Big Data and VistA EvolutionPresentati on to Open Source Electronic Health Record Alliance (OSEHRA) Architecture Work Group

Theresa A. Cullen, MD, MSChief Medical Information OfficerDirector, Health Informatics Office of Informatics and Analytics Veterans Health AdministrationDepartment of Veterans Affairs

VETERANS HEALTH ADMINISTRATION

Agenda

• Overview of the Department of Veterans Affairs (VA)

• Big Data

• VistA Evolution

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.

3

Patient

. . . .

Patient and ProviderPatient, Provider, and Patient FamilyCommunityPopulation


Overview of VA

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Hospital System to Health SystemIn 1996, VA began the creation of Veterans Integrated Service Networks (VISNs) to transform VA Health Care from a “Hospital System” to a “Health System.” Veterans Health Administration (VHA) currently has 21 VISNs.

• 134 Community Living Centers

• 300 Vet Centers

• 152 Medical Centers• 990 Outpatient Clinics

821 Community-Based 152 Hospital-Based 11 Mobile

6 Independent

• 102 Domiciliary Residential Rehabilitation Programs

Source: FY 2012 End-of-Year Pocket Card

• 70 Mobile Vet Centers

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VA’s Health Care Delivery Model

• Personalized, Proactive and Patient-Driven• Team Care• Continuous Improvement• Data-Driven, Evidence-Based• Value• Prevention / Population Health

Coordinated Care

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Big Data

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Collect and Blend the Big Data

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MIX


Broad range of clinical

programs designed to

improve care for Veterans with

complex chronic illness

Home-based primary care

Case-management

Specialty clinics, e.g., heart failure

Telehealth

Palliative care

• Providers can’t accurately predict Veterans at highest risk of deterioration

• Patient Aligned Care Team Registered Nurse (RN) Care Managers charged to coordinate care

• No systematic way to identify Veterans who might benefit most predictive analytics using data from Electronic Health Record (EHR)

Secondary Data Use: Research and Predictive Analytics Capabilities

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What’s Wrong: Data-Domain Centric• Building blocks of EHR are data domains

– Meds, Labs, Rad, Notes, Diagnoses, etc.

• Results in bad thought-flow and workflow

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Moving From What’s Wrong

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Data Silos Data Juxtaposition

Data + Workflow Integration


Implications of Conceptual Approach

• Goal - construct user-interface components to facilitate clinical reasoning and work

• Address basic cognitive needs – then reuse or reconfigure for most health care processes

• Avoid “an app for that,” while allowing for extensibility

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Standard Orders

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Developing Context-Sensitive Orders

• 30 million records – 20 years of data mined to identify relationships between– Problems– Laboratory results– Prescriptions– Procedures– Orders– Location– Provider– Patient

• 15,000 conditions and 10,000 orders

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Common Test and Drug Orders

• Epigastric pain– CBC with diff

– Chemistry panel

– Helicobacter pylori

– Lipase

– Amylase

– Upper GI endoscopy

– Abdominal ultrasound

– CT abdomen w/o contrast

•Omeprazole•Ranitidine•Amphogel•Rabeprazole•Promethazine•Sucralfate•Metronidazole•Metoclopramide•Docusate

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Characteristics of VHA Analytic Approach

• Treat corporate data as strategic resource, available to entire organization

• Maximize understanding of organizational processes and outcomes to promote learning and improvement

• Invest in relevant, role-based training in analytics so tools are available widely and not just to a few

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• For clinicians– Real-time, structured data collection– Population and panel management tools

• For leadership– Understanding organizational performance and

vulnerabilities• For public/consumers

– Unparalleled transparency and public reporting

Products

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Care Assessment Need (CAN) Report

• CAN provides estimated probability of death/hospital admission w/in specified time frame (90d or 1 yr)

• Score expressed as a percentile 0-99; higher score indicate follow-up assessment

• Provides patient level detail

• Accessible through VHA Support Service Center (VSSC) website and Computerized Patient Record (CPRS) tools menu

• For primary care providers, and/or nurse care manager

• Model developed in collaboration with VA researchers and policy leaders

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VHA’s Analytic Journey – Summary Themes

• Leverage and integrate information (break down silos) to gain insight and efficiency

• Collaborate across multiple data sources and agencies (e.g., Veterans Benefits Administration, Department of Housing and Urban Development (HUD), Department of Health and Human Services (HHS))

• Move from retrospective performance reports to real-time prediction, decision support, and practice support

• Enhance analytic skills throughout Veterans Health Administration (VHA) workforce

• Promote transparency and accountability19


VistA Evolution

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Background

• In 2013, VA and Department of Defense (DoD) Secretaries made decisions that require a change in EHR strategy

• The VA EHR core will be VistA-based• Our mission has not changed

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“to care for him who shall have borne the battle, and for his

widow, and his orphan”

VETERANS HEALTH ADMINISTRATION ‘Conceptual’ representation of current EHR/Health Information Technology Landscape

VistA Standardization

VistA

CPRSiEHR

HMP

Janus JLV

VLER Health

VistA Web

RDVs

Connected Health

Current VA Landscape

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Over the past several years, various products have been developed across the VA landscape, creating a complex suite of applications

CAPRI

Acronyms:CAPRI – Compensation and Pension Record InterchangeHMP – Health Management PlatformiEHR – integrated Electronic Health RecordJLV – Joint Legacy ViewerRDV – Remote Data Views


Roadmap

2014 2015 2016 2017

Initial Operating Capability (IOC)

Office of the National Coordinator (ONC) Certification 2014 Criteria

Interoperability

Full Operating Capability (FOC)

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VistA Evolution Management Approach

An agile-UX-Value Management approach allows high-level, very broad modeling and planning at the beginning of the project to address the

majority usability, UI, and project risks facing the team.

Value Management

Feature Driven Design

Agile Principles

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• Continuous feedback and improvement

• Engaged customers and stakeholders

• Just in time requirements

• Plan the program before starting work

• Focuses on system behavior and usability

• Requires some system modeling and design upfront


VistA Evolution Program Goals

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The VistA Evolution Program will support this strategic plan through continual investment and delivery of scalable and modular EHR and Health Information Technology (IT) products to improve the quality, safety, efficiency, and satisfaction in health care for Veterans through:

• Interoperability• Implementation of an open and extensible EHR system• Establishment of interoperability between VA and DoD EHR

systems• Re-engineering of business processes in collaboration with users

of health IT


Federal Partners

(DOD, IHS)

VistA

VBA

Standard Data Model

Inte

grat

ed A

rchi

tect

ure

and

Serv

ices

By end of 2017, we will have an architecture and framework that supports interoperability, care coordination, meaningful use and partnership and which has been certified to the Office of National Coordinator (ONC) 2017 Edition certification criteria to support meaningful use demonstration by VA providers and hospitals

Open Source/

Community Partners

Care Coordination Framework

User Experience

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Interoperability

Acronyms:DoD – Department of DefenseIHS – Indian Health ServiceVBA – Veterans Benefits Administration

VL

ER

an

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PO

def

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inte

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Technical (syntactic) Interoperability • Allows computers to reliably exchange data, so it can be read at least by humans.• Accomplished with messaging protocols and data formats.

Semantic Interoperability • Allows computers to unambiguously and consistently determine meaning of the

data for presentation and decision support.• Accomplished with standardized terminologies like ICD10 and SNOMed.

Process Interoperability • Allows computers to exchange and track workflows as patients or orders move

between organizations; includes care plans.• Accomplished with standardized business process notation or workflow protocols.

• Ex. 1: sending prescription requests from VistA to community pharmacies; • Ex. 2: tracking care plans for follow-up on cancer suspicion from X-ray• Ex. 3: continuing polytrauma care plans as patients move between VA and DoD.

Three Key Interoperability Concepts

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How Do We Get to Seamless Interoperability ?

Principles• Mapping to National Standards is the correct approach

- VA investment will improve interoperability with DoD and other health care partners

• “First No Harm”- VA must balance permitted uses of shared data with our level of

confidence in coding and content accuracy The possibility and degree of harm

• 100% mediation is NOT to be expected - Mediation rates in Clinical/Health Data Repository (CHDR) are ~80%

This is still an improvement over “No Data”

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How Do We Get to Seamless Interoperability ?

Interagency Program Office (IPO)• Provide and maintain complete, accurate, and meaningfully interoperable

data from all domains required to achieve clinical objectives and meet regulatory requirements (semantic interoperability)

VistA Evolution• Improve technical infrastructure for health data interoperability while

reducing overall system complexity (improved syntactic interoperability)• Convert to standards-based services, formats, protocols, and data models• Enable expanded and improved data exchange with partner providers

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VistA Evolution Program Objectives

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1. Provide program structure, management ,and governance to oversee requirements management, acquisition, risk management, communications, training, and transition planning.

2. Establish and maintain flexible system and enterprise architectures that support interoperability with internal and external partners, and support new applications and features that meet clinical needs.

3. Establish and maintain methods to develop business (clinical and administrative) processes and to revise existing procedures and policies that advance VA health care and health informatics capabilities.


VistA Evolution Program Principles

This VistA Evolution Program Plan is based on the following principles to ensure the highest standards of program execution:

• Focus on our Servicemembers, Veterans, and their family members.

• Enable health care that applies the appropriate and most efficient resource to the task of providing the highest quality care while maintaining a focus on prudent custodianship of tax payer resources.

• A cohesive, forward-looking architecture which maintains affordability while enabling a steady and reliable evolution forward, incorporating state-of-the-art technology while leveraging the knowledge base and processes that create a patient-centric health care environment.

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VistA Evolution Program Management

The importance, size, and complexity of VistA Evolution requires adoption of robust constructs for organization and governance structure.

• The organization of scope, schedule, and cost must include the business, technical, and program functions.

• The organizing framework must be detailed enough to practice Value Management yet ‘light’ enough to enable agile management and development when appropriate.

• The work breakdown structure must align to iEHR capabilities and to business functions

• Consensus is needed on artifacts and frameworks used to execute the program.

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The Program Plan defines the Who and How of the VistA Evolution Program• Management Approach• Governance for Program Planning, Change Control, and Risk

Management• VistA Evolution Product Approach• EHR Certification and Meaningful Use• Requirements Management Strategy• Communications Strategy• Training Strategy• Transition Strategy• Work Breakdown Structure

VistA Evolution Program Plan Purpose

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The VistA Evolution Product will:1. Deliver on the VA and DoD Secretaries’commitments to accelerate full

health data interoperability between VA and DoD2. Tie together disparate threads of clinical data into one care coordination plan

available to the entire clinical care team3. Deliver the greatest quality of care that supports the health status goals of

Servicemembers, Veterans, and family members4. Will be incrementally delivered through FY17

VistA Evolution: The Product

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The VistA Evolution product provides the infrastructure and open, extensible platform on which tools and services can be integrated in support of Veterans’ evolving needs, in pace with the technological landscape. The VistA Evolution Product will be incrementally developed and deployed through Fiscal Year (FY) 2017.


VistA Evolution Product VisionThe 4-year product vision for the VistA Evolution Product includes:

• A user experience that integrates information for improved quality of clinician and patient reasoning;

• Sharable Clinical Decision Support (CDS) to promote best clinical practices tailored to the patient's clinical condition and health-related goals;

• Capabilities for clinicians, managers, and researchers to define and manage patient populations;• Management of activities that improve human and material resource utilization and clarify plans

of care for all members of the team including the patient;• Explicit incorporation of patient goals in the care plan, to support patient-defined terms of

success, and;• Enterprise-wide deployment.• Achieve ONC 2014 Edition certification by September 30, 2015.• Achieve ONC 2017 Edition certification by September 30, 2017.

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This pathway supports the triple goals of improving the experience of care, improving the health of populations, and reducing per capita costs of health care.


Product Management: Feature Driven Design Process

• Identify Vision• Identify Projects and Teams

•Create Models

Envision

•Determine user needs from real, actual users

•Develop user personas and scenarios

• Investigate pain points in current system

• Investigate options for meeting user needs

• Investigate process tooling

Speculate•Organize user needs into Features and Feature Groups

•Develop multiple designs for Features

•Design and test Throw Away prototypes with real users

•Create lightweight Real prototypes of the best designs

•Adds/Cuts on selected designs

•Create lightweight specs for development

Explore

•Write code and implement specs

•Test features for code quality

•Test features against scenarios with real users

• Integrate with other Feature Groups and System

Adapt•Deliver product•Pass along key learning's

•Celebrate

Close

• Allows for substantial upfront design and iteration and evolution in development• This is needed to deliver features requiring highly refined design for User

Interface (UI)/User Experience (UX) controls, layout, and interaction

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VistA Evolution

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Beginning with delivery of new features by September 2014, we will analyze and begin to synthesize existing features into a new platform

A single viewer will become the starting point for a new user experience to support Patient Aligned Care Teams, patients, and the population

VistA Evolution Product

VistA legacy

Connected Health

VLER Health

CPRS

CAPRI

VistA Web

RDVs

HMP

Janus JLV

VistA Standardization

DoD iEHR

Acronyms:HMP – Health Management PlatformJLV – Joint Legacy ViewerRDV – Remote Data Views


VistA Evolution Initial Operating Capabilities (IOC): September 2014

• Capabilities enabled at two sites: Hampton Roads and San Antonio– Advanced User Interface Tools (via Health Management Platform)

• ‘Google-like’ Search across database• HL7 Context-aware ‘InfoButtons’ integrated into User Interface• Medication review tool

– VA/DoD Information Sharing (via Joint Legacy Viewer)– Immunizations

• Modernize VistA immunization files, incorporate required ‘CVX’ format• Facilitates enabling of read/write/exchange + advanced CDS in FY15• Enables new sources of adoption: VA Innovations, OpenCDS, IHS RPMS

– Laboratory Information System Acquisition• Modernization and automation of ‘back-end’ lab processes• Facilitates data exchange , business process interoperability, and enhanced CDS

– VistA Standardization• Certification of 74 standardized VistA application routines in production (complete)

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ONC 2014 Edition Certification of VistA

• ONC 2014 Edition Certification Criteria– VA intends to certify 46 criteria by September 30, 2015– The following criteria will not be certified:

• 170.314(f)(5) Cancer Case Information (optional)• 170.314(f)(6) Transmission to Cancer Registries (optional)• 170.314(g)(1) Automated Numerator Recording (VA will certify

170.314(g)(2) Automated Measure Calculation instead)

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VistA Evolution Full Operating Capability (FOC): September 30, 2017

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Phase Two of the VistA Evolution is referred to as FOC and will be implemented from the end of IOC (September 30th, 2014) and completed by September 30th, 2017.

The functional focus areas for FOC will:• Propagate the usability features and end-user experience throughout all VistA Evolution to improve user

adoption, productivity, and satisfaction;• Continue the adoption and implementation of interoperability standards for sharing clinical records

across organizations;• Enable patient-centered care coordination as the care model woven throughout the design, and;• Finalize the enterprise deployment of state-of-the-art laboratory and pharmacy ancillary systems, while

leveraging process re-engineering to ensure best practice operations for efficiencies, quality of care, and patient safety.

The resulting VistA Evolution FOC application suite and underlying technical architecture will represent a state-of-the-art enterprise EHR solution that has been certified to the forthcoming ONC 2017 Edition certification criteria.


Keeping the Patient in Focus

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Questions?

Contact Information:Theresa Cullen, M.D, [email protected]

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mailto:[email protected]

big data and vista evolution, theresa a. cullen, md, ms

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