IT Support for the Care of OEFOIF Veterans Susan Lloyd Acting Director, Enterprise Systems Managemen

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IT Support for the Care of OEF/OIF Veterans
Susan LloydActing Director, Enterprise
Systems ManagementTravis HoffmannActing ESM,
Health Data SystemsMarcia InsleyPortfolio
Manager, Health Data Systems
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Veterans Health Administration (VHA)
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VHA IT Structure
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Todays Goal

• This course will serve to educate attendees about
  the wide variety of IT initiatives, designed to
  support OEF/OIF veterans, that either currently
  exist or are under development and will be rolled
  out to the field over the next 6 - 18 months

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Initiative Breakdown
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• Background

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The Challenge

• In the past year, there have been new
  presidential task forces, recommending
  commissions, and governance structures set up
  all in response to the pressing need to care for
  the wounded warrior returning from the theater of
  operations
• Number of deployments 2,200,000
• Number of service members deployed 1,500,000
• Air evacuated for illness or injuries 37,851
• Wounded in action 28,000
• Treated and returned to duty within 72 hours
  23,270
• Seriously injured (Traumatic Service members
  Group Life Insurance recipients) 3,082
• Traumatic Brain Injuries 2,726
• Amputations 644
• Serious burns 598
• Polytrauma 391
• Spinal cord injuries 94
• Blind 48
• THE PRESIDENTS COMMISSION ON CARE FOR AMERICAS
  RETURNING WOUNDED WARRIORS, JULY 2007

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Task Forces and Recommending Bodies

• Presidents Task Force to Improve Health Care
  Delivery for Our Nations Veterans May 2003
• Presidents Task Force on Returning Global War On
  Terror Heroes (GWOT) April 2007
• Independent Review Group (IRG) April 2007
• DoD Task Force on Mental Health June 2007
• Presidential Commission on Care for Americas
  Returning Wounded Warriors July 2007

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Governance Structures

• Old governance structures were utilized (Joint
  Executive Council) and new governance structures
  were set up (Senior Oversight Committee) to
  manage the recommendations from the task forces

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Joint Executive Council

• The JEC is responsible for overseeing all sharing
  initiatives between the two Departments
• Co-chaired by each Departments Deputy Secretary

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Joint Executive Council
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Senior Oversight Committee (SOC) Background

• In March 2007, as a result of the Walter Reed
  press, Under Secretary for Defense Personnel
  Readiness (USD PR) testified to Congress. Upon
  his return to the office, he established the
  Support and Care of the Wounded (SACW) Task
  Force.
• After 60 days, the SACW Task Force concluded.
  One of the products from the SACW was a joint
  VA/DoD structure to oversee ongoing efforts and
  guide new activities related to wounded, ill, or
  injured personnel and their families
• Senior Oversight Committee was formed to drive
  related Wounded Warrior efforts/activities to
  provide comments/recommendations by December 2007
• On March15, 2007, The Wounded Warrior Act of 2007
  (H.R.1538) was introduced in the House and on
  July 25, 2007 Senate amendments were received
• On July 30, 2007, the Final Report of the
  Presidents Commission on Care For Americas
  Returning Wounded Warriors was released by Dole
  and Shalala
• H.R.1538 will be reviewed in light of the
  Presidents Commission Final Report

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Senior Oversight Committee (SOC) Structure
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• Major Project Focus Areas

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Major Project Focus Areas

• VA/DoD Data Exchange
• Patient Tracking
• Case Management
• Specialized Registries
• Simplified Registration Process
• CPRS Flags/Markers
• Joint Inpatient EHR
• E-Benefits Portal

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• VA/DoD Data Exchange

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VA/DoD Data Exchange Current Data Exchange
Methods
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Federal Health Information Exchange

• Operational at all VA Medical Centers since 2002
• Permits VHA clinicians and VBA disability claims
  processors to view historical DoD data Patient
  Demographics for Identity Management, Laboratory
  results, Radiology reports, Outpatient Government
  and Retail Pharmacy data, Allergy data,
  Admission, Disposition and Transfer (ADT) data,
  Consultation Reports, Discharge Summaries, and
  outpatient coding from DoDs Standard Ambulatory
  Data Record
• Also able to view through CPRS historical pre-
  and post-deployment health assessment (PPDHA)
  data on separated Service members. These data
  are collected prior to and immediately following
  deployments by Service Members, Reserve and
  National Guard members and include
• Patient Identity
• Deployment locations
• Immunizations
• Hazardous exposures
• Physical and mental health assessments

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Bi-directional Health Information Exchange (BHIE)

• BHIE brings real-time, bidirectional exchange of
  current medical information reusing FHIE
  infrastructure between CHCS and VistA CPRS
  current health information systems
• Accessed via Remote Data Views in CPRS or VistA
  Web
• Currently sharing
• Demographics
• Outpatient Pharmacy
• Allergies
• Chemistry Hematology Results
• Radiology Reports
• Clinical Notes
• Procedures
• Encounters 
• Theater Data
• Future sharing
• Lab Anatomic Pathology (AP) Vital Signs June
  2008
• Family History, Social Other History,
  Questionnaires, and Forms Sep 2008
• Scanned and Imported Documents and Images Dec
  2008

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Remote Data Screenshots - CPRS
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Remote Data Screenshots CPRS cont.
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Remote Data Screenshots CPRS cont.
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Remote Data Screenshots VistA Web cont.
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Remote Data Screenshots VistA Web cont.
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Clinical Data Repository/ Health Data Repository
(CHDR)

• CHDR allows computable data to be shared between
  VA and DoD
• Uses an agreed terminology standard as a
  translator into each agencys native vocabulary
• Data is persisted from DoD and becomes part of
  the VA patient's medical record and vice versa
• CHDR Functions
• Establish ADC Standalone application to mark
  patients having dual care eligibility as Active
  Dual Consumers
• Data Exchange Flow An initial exchange of data
  at marking, and subsequent flow whenever one
  side or the other has new data to share
• Currently sharing Outpatient Pharmacy and Allergy
  information
• Allows Drug-Drug and Drug-Allergy Order Checks
• Currently rolled out to field test sites
• National Deployment under way
• Next domain to be shared Laboratory data
  (chemistry and hematology)

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Drug-Drug Order Check in CPRS

• VA clinician writes a new order

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Drug-Drug Order Check in CPRS cont.
CPRS order check warns of a significant drug-drug
interaction with the existing DoD (4th Medical
Group) prescription
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Drug-Drug Order Check in CPRS cont.

• CPRS Patient has an existing allergy received
  from DoD via CHDR stored in the HDR

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Drug-Drug Order Check in CPRS cont.

• The VA clinician writes new order

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Drug-Drug Order Check in CPRS cont.

• Order checking warns of a significant
  drug-allergy interaction between the DoD allergy
  for HYDROCHLOROTHIAZIDE and the attempted VA
  prescription for HYDROCHLOROTHIAZIDE.
• Remote allergy source is not available in CPRS.

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VA/DoD Data Exchange - Future Interoperability
FY08
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VA/DoD Data Exchange - Future Interoperability
FY09
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Nursing VA/DoD Transfer Summary

• Allows VA and DoD to share SBAR (Situation,
  Background, Assessment, Readiness) summary of
  patient being transferred between DoD (Walter
  Reed) and VA (Polytrauma Centers in Richmond,
  Minneapolis, Palo Alto, and Tampa)
• Note is created in Essentris on the DoD side and
  CPRS on the VA side
• Data is shared using existing BHIE framework and
  viewable via a remote data view in CPRS
• Currently in pilot mode between Tampa and Walter
  Reed
• After successful proof of concept on pilot level,
  additional plans for rollout will be evaluated to
  additional sites.

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Lab Data Sharing Interoperability (LDSI)

• Allows VA and DoD to use each others agency as a
  reference laboratory
• Enables the electronic sending and receiving of
  orders and results for Anatomic Pathology and
  Microbiology laboratory tests between the VA and
  the DoD (as well as intra-VA and intra-DoD)
• Currently, laboratory technologists enter AP
  Micro orders and results manually. In addition,
  identifying traits must be manually entered. The
  set-up required for each test order in the
  computer can also be significant
• With LDSI the laboratory manager will enter a
  one-time set up for a given type of test
  ultimately saving thousands of hours across the
  agencies over time
• A marked reduction in turnaround time for the
  tests is expected with the new functionality as
  well as the elimination of manual entry errors
• To be rolled out nationally 1Q FY09

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National Health Information Network

• Address and comply with Executive Order 13410
  Promoting Quality and Efficient Health Care in
  Federal Government Administered or Sponsored
  Health Care Programs
• Requires federal agencies to use recognized
  health interoperability standards to promote the
  direct exchange of health information between
  federal agencies and with non-federal entities in
  supporting quality and efficient health care
• The Veterans Health Administration has a role in
  supporting the wide spread adoption of
  interoperable electronic health records and
  provide a mechanism for sharing the health
  information between federal and non-federal
  organization nationwide

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• Patient Tracking

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Veterans Tracking Application

• Patient tracking and management application that
  collects, manages, and reports on patients
  arriving at DoD facilities in the US from
  forward-deployed locations
• Allows user to see
• Where veteran/service-member is currently located
• Where the patient came from
• Who has seen the patient
• Where veteran/service-members filed claims
• Used by VHA and VBA staff to ease transition,
  track patients, and assist with claims processing
• Currently used by Federal Recovery Coordinators
  (FRC) to develop Federal Individual Recovery Plan
  (FIRP)

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Veterans Tracking Application cont.
Tracking patients through the Continuum of Care
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Veterans Tracking Application - Screenshots
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Veterans Tracking Application Screenshots cont.
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Veterans Tracking Application Screenshots cont.
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Veterans Tracking Application Screenshots cont.
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Veterans Tracking Application Screenshots cont.
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Veterans Tracking Application Screenshots cont.
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• Case Management

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Case Management Tracking Application (CMTRA)

• Used by Case Managers and Program Managers at the
  medical facilities to document their workload and
  case activity

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• Specialized Registries
• Traumatic Brain Injury
• Embedded Fragment
• Military Eye/Vision Injury

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Traumatic Brain Injury (TBI) Registry

• The TBI Second Level Evaluation template
  integrates into the Computerized Patient Record
  System (CPRS) and also into a database within the
  VISN Support Services Center (VSSC)
• The TBI Second Level Evaluation is a template
  developed to evaluate patients returning from an
  OEF/OIF deployment who either screened positive
  on all 4 questions contained in the primary TBI
  screening tool in CPRS, or were previously
  diagnosed with a TBI prior to coming to the VA.
  There are subsections within the TBI Second Level
  Evaluation that look at patient demographics,
  mechanism of injury, symptoms, and treatment plan
• Short term solution in operation, long term
  approach is currently underway

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TBI Registry Screenshots

• Second level evaluation activated from the CPRS
  Tools menu

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TBI Registry Screenshots
The starting page allows for searching the site
for the correct location and note title
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TBI Registry Screenshots
Assessment completed using template provided
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Embedded Fragment Registry

• To provide appropriate medical care and follow up
  for veterans with embedded fragments, metal or of
  other potentially hazardous materials resulting
  from injuries sustained during their tour of duty
• Information in this registry will be used to
  provide appropriate medical care and follow up
  monitoring
• In support of the Toxic Embedded Fragment
  Surveillance Center
• Not yet started currently awaiting funding

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Embedded Fragment Registry Proposed Approach

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Military Eye/Vision Injury Registry

• To provide appropriate medical care for veterans
  with significant eye injuries which are commonly
  associated with traumatic brain injuries, it is
  essential to provide VA clinicians with access to
  a single registry that easily identifies these
  veterans as they transition to the VA
• Information in this registry will be used to
  provide appropriate medical care, blind
  rehabilitation and follow up monitoring
• In addition, once data is captured it must be
  transmitted back to the DoD to track longitudinal
  outcomes of treatments and safety devices
• Not yet started currently awaiting funding

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• Simplified Registration Process

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Veterans Online Application

• This project would improve the Online 1010 EZ
  and 1010EZR by
• Adding e-authentication and e-signature
  capabilities
• Implementing a guided user interface
• Reducing veteran data entry burden
• Correctly identifying OEF/OIF veterans
• Improving the forms usability
• Addresses the following issues
• The enrollment selection does not have an option
  to signify OEF/OIF veterans
• There is no way to leave the form online and
  return without losing all previously entered
  information
• Online application does not provide
  e-authentication or e-signature capabilities.
  Veterans must mail in a signed form, or appear
  in person at a VHA facility to sign their
  application before processing can begin

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Military Service Data Sharing

• Enhance VistA and Enrollment Systems Redesign to
  obtain and process veterans military service
  combat information from the VA/DoD Identity
  Repository (VADIR) to establish VA health care
  enrollment eligibility
• This assists VA in providing priority health care
  service mandates for OEF/OIF combat veterans

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• CPRS Flags/Markers

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Polytrauma Marker

• In order to provide the necessary specialized
  support and care for veterans with blast-related
  polytrauma injuries, it is essential to provide a
  means of easily identifying these veterans in the
  electronic health care record
• Clinicians need a way to quickly identify
  veterans with polytrauma injuries and Congress
  and Department of Veterans Affairs (VA) requires
  a means of tracking and reporting the care
  provided to these veterans
• Also includes the development of appropriate
  polytrauma clinical alerts/ reminders and/or
  templates

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OEF/OIF Marker

• Patients seeking care at our medical facilities
  that have a status of Operation Iraqi
  Freedom/Operation Enduring Freedom (OIF/OEF)
  and/or are Active Duty need the highest priority
  in receiving appointment consideration
• There have been instances of delays in care to
  these patients because there is currently no way
  to distinguish these patients from others when
  scheduling appointments
• The objective of this request is to provide
  scheduling and clinical staff with the
  information that will allow them to prioritize
  appointment setting for these patients
• To be implemented as part of CPRS v27n in Sep
  2008

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• Joint Inpatient EHR Study

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Joint DoD-VA Inpatient Electronic Health Record
(eHR) Feasibility Study
Electronic Medical Record Integration. Report on
progress to implement a study on the feasibility
of conducting a joint acquisition for a new
common inpatient electronic health record system
as agreed to by the Secretary of Veterans Affairs
and the Secretary of Defense. The study will
assess every new clinical and business
application in our requirements inventory for
potential joint application. In addition, VA and
DoD have been directed to provide the Senate a
project plan in May 2007.
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Joint DoD/VA EHR Project Objectives

• Document and assess DoD and VA inpatient clinical
  processes, workflows, and requirements
• Define the scope/elements of an inpatient EHR
• Define clinical/business capabilities/applications
  that interact with the inpatient EHR
• Document the inpatient EHR functionality and
  requirements (clinical functionality,
  administrative functions and business rules)
  represented by VHAs current VistA CPRS and next
  generation inpatient EHR (subset of the
  HealtheVet program)
• Assess the DoD inpatient EHR requirements and
  constraints and map against the functionality and
  requirements as defined for VistA / HealtheVet
• Provide top-level assessment of potential costs,
  schedule and risks to develop Department-unique
  and joint inpatient EHR functional requirements
• Document any head-start opportunities for
  DoD-VA interoperability and sharing of healthcare
  information
• Currently reviewing proposed solutions for a
  Joint Inpatient EHR
• Final recommendation due in July

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• E-Benefits Portal

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E-Benefits Portal

• DoD and VA should make information about benefits
  and services available online, via a
  password-protected site), in which service
  members and veterans can securely enter personal
  information
• A secure Service Member/Veteran centric portal
• Focused on health, benefits, and services
• Support needs of the individual and their family
  members or other delegates
• A source that is customized to the needs of the
  Service Member /Veteran that is
• relevant to their circumstances
• Leverages processes appropriate to support
  beneficiary needs
• tailored to their physical location
• tailored to their physical limitations
• Providing as much self service capability as is
  possible and/or needed
• A platform that all future portal activities
  surrounding benefits will leverage when planning
  initiatives
• The scope for the eBenefits Portal is to not
  replace all VA and DoD portal activities, but to
  initially leverage and integrate existing portals
  such as My HealtheVet (MHV), the Veterans
  Information Portal (VIP), Army Knowledge Online
  (AKO), Defense Knowledge Online (DKO), Tricare
  Online (TOL), and others
• Currently in Requirements Development

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Upcoming Site Visits
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Key Takeaways

• Become as familiar as possible with the projects
  so that you can inform end users where and how to
  find the right information
• Look out for the projects being implemented

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Contact Information

• Susan Lloyd
• 202-245-4013
• Susan.lloyd2_at_va.gov
• Travis Hoffmann
• 202-245-1826
• Travis.hoffmann_at_va.gov
• Marcia Insley
• 202- 245-4504
• Marcia.Insley_at_va.gov

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Questions
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• Backup Slides

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SOC Line of Actions (LOAs)
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SOC Line of Actions (LOAs)
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SOC Line of Actions (LOAs)