VeHU 143 Ill share if you share: VA DoD Clinical Information

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VeHU 143Ill share if you shareVA DoD Clinical
Information

• W. Paul Nichol, MD
• National Director Medical Informatics
• Patient Care Services
• Dick Rickard. PMP
• Project Manager CHDR RDI
• Greg Donham, MSInteragency Program Manager
• BHIE/FHIE Program Office

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Session Overview

• Evolution
• VA/DoD Joint Electronic Health Records
  Interoperability Plan - Overarching Strategy
• The Path to Interoperability
• Federal Health Information Exchange (FHIE)
• Bidirectional Health Information Exchange (BHIE)
• Pre and Post Deployment Health Assessment Data
• Clinical /Health Data Repository
• Other Ongoing Integration Efforts

3
Team Puget SoundNDAA IT Sharing Demonstration
Project
Local VA DoD Sharing
Madigan Army Medical Center
VAPSHCS American Lake Campus
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Evolution of VA DoD Data Sharing

• Phone/Fax/Paper
• Local EMR Enhancements/ copy-paste/ scan
• Remote log on
• VPN/ SSL to CPRS
• SSL to ICBD/HealtheForces
• Record Flags Active Inpatient/ DoD Treatment
• CPRS Patient List
• Progress Note
• Discharge Summary copy/paste to CPRS

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VA/DoD Joint Electronic Health Records
Interoperability Plan Overarching Strategy
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VA/DoD Electronic Health Record

• Joint Electronic Health Records Interoperability
  (JEHRI) Plan
• Developed collaboratively by VA DoD
• Approved by the VA/DoD Joint Executive Council
  (JEC) and signed by the VA Under Secretary for
  Health (USH) and DoD Assistant Secretary of
  Defense, Health Affairs (ASD(HA))
• Approved by OMB
• Provides the roadmap to achieve VA/DoD
  interoperability
• Two Phases
• Phase I One way electronic data exchange
• Phase II Bidirectional and computable data
  exchange

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VA/DoD Electronic Health Record

• JEHRI Goals
• Improve sharing of clinically relevant
  information
• Adopt common standards for architecture,
  security, communications, data, technology and
  software
• Seek joint procurements and/or building of
  applications
• Seek opportunities for sharing existing systems
  and technology
• Explore convergence of VA and DoD health
  information technology applications where
  feasible and within mission requirements
• Develop interoperable health records and data
  repositories

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The Path to VA/DoD Interoperability
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DoD/VA Interoperability Initiatives
VA
DoD
One-way, enterprise exchange of text data
FHIE
FHIE
Bidirectional real-time exchange of text data
BHIE
BHIE
Bidirectional real-time enterprise exchange of
computable data
CHDR
CHDR
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Federal Health Information Exchange
(FHIE)Information Sharing in Operation
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Federal Health Information Exchange (FHIE)

• Successfully completes Phase I of JEHRI
  operational at all VA medical centers since
  2002---Fifth Anniversary on Memorial Day !
• One-way transmission of electronic military
  health data from DoDs legacy health information
  system, CHCS, to VAs VistA Computerized Patient
  Record System (CPRS) the point of care
• Averages over 17,000 uses of FHIE/BHIE data each
  week (compared to 8,200 last year)
• DoD has transmitted data to the FHIE repository
  on approximately 3.7M unique patients
• VA has provided care or treatment or benefits to
  over half of the unique DoD patients using FHIE
  data
• 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
• Intergovernmental Solutions Finalist, 2005

As of 9 May 2007
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Pre Post Deployment Health Assessments

• Re-used FHIE architecture to support the ability
  of VA clinicians and VBA examiners to view with
  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
• Operational in VA since December 2005
• DoD has transmitted over 1.7M PPDHA on more than
  700,000 individuals who are separated Service
  members and Reserve and National Guard Members
  who have been deployed and are now demobilized
• DoD continues to send monthly updates provided to
  VA containing data on separating Service members
  and demobilized Reserve and National Guard
  Members
• Operational in VA since December 2006, DoD Post
  Deployment Health Reassessment data is available
  from DoD through weekly transmissions for
  follow-up care in VA

As of May 2007
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CHCS-VistABidirectional Health Information
Exchange (BHIE)Bridging the Gap
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BHIE Interoperability Goals

• To provide the best healthcare possible to the
  U.S. Military and our Veterans
• Operate a joint system for transfer of electronic
  health information between DoD and VA that
  contributes to veterans health
• Provide on-demand electronic health information
  to assist in the compensation process
• Ensure compliance with HIPAA regulations and
  security requirements with existing systems
• Create an environment for storing very sensitive
  information
• Use a patient-focused information technology
  familiar to authorized VA and DoD users

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Bidirectional 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
• BHIE supports the care of shared patients at
  joint sites, including dependents
• Bidirectional transmittal and display of
• Patient Identification Management
• Outpatient pharmacy information
• Allergy data
• Laboratory result data, including microbiology
  and pathology reports
• Radiology text reports
• Discharge Summaries
• Initial VA implementation in October 2004 and now
  operational at all VA sites and select DoD sites
  worldwide
• Currently exploring increasing domains of data
  available through BHIE
• Recipient of the Excellence.gov Award in 2006

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High-Level FHIE/BHIE Architecture
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BHIE Sites Current and Pending
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BHIE Data Access
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FHIE/BHIE - Remote Data Viewing

• Data types now available
• Outpatient medications
• Allergies
• Lab Chemistry, Hematology, Micro, Path, etc
• Radiology Text Reports
• Pre and Post Deployment Assessments
• Post Deployment Health Re-Assessment
• Discharge Summaries (10 VA DoD Essentris Sites)
• Data types in the works
• Patient identifiers for OEF/OIF, TBI, Polytrauma
• Priority being given to data to support returning
  veterans
• Progress notes and consultation reports
• Inpatient medications
• Problem list
• Imaging

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BHIE - Remote Data Viewing

• VA
• CPRS Remote Data Views
• VistA Web
• CPRS-R
• DoD
• SHARE
• AHLTA

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Screen Shots CPRS
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Screen Shots CPRS
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Screen Shots CPRS
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Screen Caps - VistaWeb
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Screen Caps - VistaWeb
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Screen Caps - VistaWeb
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Screen Shots SHARE
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Screen Shots SHARE
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Screen Shots SHARE
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NDAA VA DoD IT Sharing Demonstration Project

• FHIE-BHIE-C/HDR
• National Defense Authorization Act (NDAA) in FY
  2003 funded 3 VA DoD IT Sharing Demonstration
  Projects
• Team Puget Sound (MAMCVAPSHCS) Project
  components
• Data Exchange
• Implementation Guides HL7 CDA
• User Interface Requirements
• Other NDAA Projects
• Reference lab data exchange
• Credentialing and privileging

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Project Goals/Objectives
The objective of the Team Puget Sound (TPS)
National Defense Authorization Act (NDAA)
Demonstration Project is to develop the
requirements and capabilities to ensure that
relevant patient information is readily
accessible electronically to clinicians at both
VA and DoD sites and displayed in a clinical
useful manner.
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Limitations
Some limitations of current status

• Incomplete document types
• Limited encounter/ billing data
• Incomplete medications (no inpatient meds/OTC)
• No problem list
• No provider contact information
• No advance directive information
• Clinical reminders do not cross systems
• Limited functionality of user interface
• Inability to graph
• No worksheet view
• Limited ability to customize, manipulate views
• Not context sensitive
• No decision support

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Major Accomplishments

• Technical Documentation (TD)
• Completed CDA R1 Implementation Guide - Oct 05
• Completed CDA R2 Implementation Guide May 06
• Completed OV, SV, TV Nov 06

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CDA R1 Implementation Guide

• Completed in October 2005.
• Used in TPS Cycle 1 as a container for
  unstructured text body.

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CDA R2 Implementation Guide

• Completed in May 2006.
• Used in TPS Cycle 2 and 3.
• Based on Care Record Summary (CRS) Implementation
  Guide.
• Written with other MHS and VA implementations in
  mind.
• Will be used in Essentris to BHIE interface for
  MAMC inpatient notes.
• By keeping to the CDA standard, interfaces with
  other partners will be easier.
• Used as an example for other CDA R2
  implementation guides written by MHS and HL7
  organizations.

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CDA R2 Example
Discharge Summary in CDA HEADER (not a complete
example)
sheet type'text/xsl' href'IMPL_CDAR2.xsl'? nicalDocument xmlns'urnhl7-orgv3'
xmlnscrs'urnhl7-orgcrs' xmlnsxsi'http//www.
w3.org/2001/XMLSchema-instance' extension'12345_200603231855' root'2.16.840.1.11
3883.3.42.2.0125'/ displayName'SUMMARIZATION OF EPISODE
NOTE' codeSystem'2.16.840.1.113883.6.1'
codeSystemName'LOINC'/ MADIGAN ARMY
MEDICAL CENTER DISCHARGE SUMMARY veTime value'200603231855040500'/ t root'2.16.840.1.113883.3.42.3.0125'/
. ityAnywhere XX talCode00000 USAry 0' use'HP'/ Mr. VA DoD ilyPatient One . . . . . .
. . . .
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CDA R2 Example
Discharge Summary in CDA Structured Body (L2)
(not a complete example)
ion 1.113883.6.1' displayName'HOSPITAL
DISCHARGE DX'/ Conditions
Severe COPD w/ exacerbation on
5L as an outpt, PFTs mmm YY
DLCO 2.33, TLC 5.3, Vc 2.9, Frc 3.33, RV
2.4 Pre-bronchodilator FVC 2.39, FEV1
1.16, FEV1/FVC 46
Post-bronchodilator FVC 2.54, FEV1
1.16, FEV1/FVC 46 Severe obstruction w/ no
post-bronchodilator response.

codeSystem'2.16.840.1.113883.6.1' displayNam
e'HISTORY OF ALLERGIES' / Allergies
. . . . /component icalDocument
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Major Accomplishments

• Information Exchange Technology (IET)
• Completed BHIE Phase 1 (Bidirectional)
• Patient Identification
• Allergies
• Prescriptions
• Completed BHIE Phase 2 (Bidirectional)
• Laboratory Results
• Radiology (reports)
• Completed TPS Cycle 1 (DoD to VA)
• Inpatient Discharge Summaries via GDNii using CDA
  R1
• Completed IDS CLIN 1 / BHIE Phase 3
  (Bidirectional)
• Inpatient Discharge Summaries from Essentris and
  VistA
• Completed TPS Cycle 2 (DoD to VA)
• Historical outpatient notes from GDNii using CDA
  R2 format
• In progress Migration of IDS CLIN 1 to CDA R2
  format

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TPS User Interface Requirements Methods

• Interviews
• Surveys
• Structured questions
• Heuristc evaluation
• Uses cases/ stories
• User personae
• Scenario based diagnostic usability tests

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VA DoD Data Sources for Sharing
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TPS IT Sharing Identified Data Needs
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Alternate Interfaces
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TPS NDAA VA DoD IT Sharing Demo
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Lessons Learned

• Significant differences exist between VA and DoD
• Information systems
• Policies and practice
• Workflow/ business practice
• Terminology/expectations
• Many end-user requirements for use of remote data
  are similar between VA and DoD between VAs, and
  between VA and private or affiliated health care
  systems

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Lessons Learned

• Discharge Summary Example
• Seven different discharge documents, including
  summary, note, and ER discharge note
• DC Summary contains billing information with ICD
  and CPT codes but not narrative
• Multi-disciplinary discharge note looks most like
  VA DC Summary but
• Not authenticated by signature of responsible
  physician
• Remains editable by members of the care team
• Resident determines complexity of care and need
  for formal dictated summary

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Lessons Learned

• Direct patient care benefits will increase as
  users gain familiarity/experience and
  capabilities expand
• Continuity
• Improved case management capabilities
• Safety
• Medication reconciliation
• Efficiency
• Reduced redundancy
• Timesaving in clinical process flow
• Timeliness

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Lessons Learned

• Best access to remote data is integrated into
  local EMR, or at least context linked
• Maintenance of multiple accounts not viable
  solution
• Security and firewall issues are complex
• Communication across systems is critical
• Verify assumptions and direction regularly
• Downtime issues
• Differences in ability to handle different
  document types needs to be addressed
• There is room for significant improvement in the
  user interface opportunity for joint
  development

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LessonsLearned HIMS View

• Differing document definitions
• Discharge summary vs Multi-disciplinary discharge
  note
• Version control
• Handling amended/corrected records
• Best if records are maintained by parent facility
  and accessed when needed, rather than keeping a
  local copy
• Record signing/authentication policies differ and
  need to be understood
• Care is documented in system where patient is
  seen, even care provided by VA staff at DoD
  facility
• Potential for more extensive access to data
  across VA and DoD systems than veterans may be
  aware of at present
• Differences in coding may exist but dont impact
  current reimbursement mechanisms between VA and
  DoD

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Lessons Learned

• Positive Aspects of VA DoD Environment
• Common patient identifiers, correlation
  framework, and secure exchange environment
  (through BHIE) is a huge advantage
• Sharing agreements in place in many locations
• Information exchange covered by Privacy Act
  Routine Uses 43 and 47
• Common mission and patient population
• Local and enterprise staff with extensive
  experience in electronic medical records

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Summary

• Data exchange capabilities are rapidly expanding
  between VA and DoD
• Computable data will be increasingly available to
  support activities like order checks (RDI) and
  decision support
• Standards/Standardization and improved user
  interfaces are needed to optimize systems
• It will be a challenge to keep clinical practice
  patterns, workflow, and policies up to date with
  technologic capabilities but well worth the
  effort

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Summary of CHDR/BHIE/FHIE Features

• BHIE and FHIE have a larger number of available
  reports such as Radiology, Lab, and Pre/Post
  Deployment Assessments.
• CHDR allergy and pharmacy data will be used in
  drug/drug and drug/allergy interaction alerts

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The Clinical Data Repository / Health Data
Repository (CHDR) The Interoperable Health
Record
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Where CHDR Fits
Supports interoperability between DoDs Clinical
Data Repository (CDR) VAs Health Data
Repository (HDR)
Two-way, enterprise exchange of computable data
between next-generation systems
57
CHDR Overview

• What CHDR does
• Enables the VA's HDR and the DoD's CDR to
  exchange computable data
• 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
• How it does it and how it is used
• Standardization Mediation Uses an agreed
  terminology standard as a translator into each
  agencys native vocabulary
• Persisted Data from DoD becomes part of the VA
  patient's medical record and vice versa
• Query RDV VistAWeb (DoDs AHLTA)
• Decision Support RDI (DoDs PDTS) real time
  drug-drug and drug-drug allergy alerts

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CHDR Program Structure

• Program and Project Management
• Mirrored within each agency
• Interagency Program Support Office with manager
  and shared contract support staff providing
• Liaison for interagency communications and issue
  management
• Oversight of Interagency Project Management Plan
• Oversight of agency internal and interagency
  dependencies
• Facilitation of standardization and mediation
• Autonomy and Interdependence
• Common requirements, products and timelines
• Independent management of agency issues and
  responsibilities
• Independent culture and processes (e.g. Field
  Test, Release)
• Agencies determine their own mechanisms for
  processing data in their respective applications

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Domain Sequencing

• Initial Domains Outpatient pharmacy and drug
  allergy
• Began exchanging data for Active Dual Consumers
  June 2006
• Field Test complete at seven VA-DoD joint venture
  sites
• El Paso VA HCS and Wm Beaumont AMC
• Augusta VAMC and Eisenhower AMC
• VA Gulf Coast HCS (Pensacola) and NH Pensacola
• VA Puget Sound HCS and Madigan AMC
• N. Chicago VAMC and NH Great Lakes
• VA San Diego HCS and NMC San Diego
• VA Southern Nevada HCS (Las Vegas) and Mike
  OCallaghan Fed Hospital
• National deployment scheduled for this year
• Next Domain Laboratory data (chemistry and
  hematology)
• Future Domains Under consideration

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Order Checks
Original
VA
Local VistA
Local Order Checks
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Order Checks (cont.)
With RDI
VA
Local VistA
Agency Order Checks
HDR
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Order Checks (cont.)
With RDI CHDR
VistA, VistAWeb, CHDR, etc.
AHLTA, PDTS
VA
DoD
Local VistA
Interagency Order Checks
HDR
CHDR Services
CHDR Services
CDR
VA Master Patient Index
Patient Index
STS (Mediation)
TSB (Mediation)
ADC File
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VistAWeb CHDR (DoD) OP Pharmacy
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VistAWeb CHDR (DoD) Allergy
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CPRS Drug-Drug Order Check

• VA clinician writes a new order.

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CPRS Drug-Drug Order Check

• CPRS order check warns of a significant drug-drug
  interaction with the existing DoD (4th Medical
  Group) prescription.

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CPRS Drug-Allergy Order Check

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

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CPRS Drug-Allergy Order Check

• The VA clinician writes new order.

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CPRS Drug-Allergy Order Check

• 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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Implementation Status

• National Deployment strategy
• Manual, controlled implementations
• RDI First decision support tool
• CHDR Site sharing relationships (DoD)
• RDI Project
• Product released in June 2007
• Deployment update
• CHDR Project
• Product release date
• Deployment plans

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Lessons Learned

• Things to be aware of
• Centralized architecture
• Different way of thinking
• Field Test Data (since June 2006)
• Many sites have already been seeing DoD data
• Duplication between computable and non-computable
  data (query functions)
• DoD terms that fail mediation are not included in
  VA order checks or the VA record

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Other Ongoing Integration Efforts

• Laboratory Data Sharing and Interoperability
  (LDSI) Supports the electronic ordering and
  results retrieval of chemistry laboratory tests
  between DoD and VA facilities
• Enterprise Architecture Joint VA/DoD Shared
  Health Architecture Plan/Charter completed a
  Shared Health Architecture, version 1.0 in
  December 2004
• Scheduling Interoperability Chartered work
  group exploring the feasibility of creating
  interoperable scheduling applications
• e-Health collaboration VA/DoD shared objectives
  for cooperation between TRICARE Online and My
  HealtheVet

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New Initiatives

• Veterans Tracking Application (VTA)
• Traumatic Brain Injury (TBI)
• Theater Medical Data Store (TMDS)
• Polytrauma Patient Marker
• OEF/OIF Patient Marker
• Clinical Transfer or Electronic Patient Hand-off
• DoD CPRS Paper Record Scanning Interface
• Polytrauma Imaging
• Joint Inpatient Health Record Study
• Nationwide Health Information Organization (NHIO)
  OR VHIE
• Multiple initiatives in the VBA arena

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Q A

• Questions?

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FOR FURTHER INFORMATION

• W. Paul Nichol, MD, National Director Medical
  Informatics, Patient Care Services,
  Paul.Nichol_at_va.gov
• Greg W. Donham, MS, Interagency Program Manager,
  BHIE/FHIE Program Office, Greg.Donham2_at_va.gov
• Jack Mandel, Program Manager, CHDR Program
  Office, Jack.Mandel_at_va.gov
• Dick Rickard, PMP, Project Manager, CHDR RDI
  Dick.Rickard_at_va.gov

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Back up slides
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Services Standard Interfaces
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CPRS Drug-Allergy Order Check

• 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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Acronym List

• BHIE Bidirectional Health Information Exchange
• CDA Clinical Documentation Architecture
  (national standard for information transfer)
• CHCS Clinical Health Composite System (DoD
  legacy system that houses order entry and labs,
  radiology reports, allergies, and medications
• DoD Department of Defense
• EMR - Electronic Medical Record
• ICDB Integrated Clinical Data Base (MAMC legacy
  documentation system)
• IET - Information Exchange Technology
• MAMC Madigan Army Medical Center
• NDAA National Defense Authorization Act
• SHARE Secure Healthcare Alliance Record
  Exchange (web based repository of CHCS and
  Essentris data to be used as portal that BHIE
  retrieves information from to send to VA system)
  
• TPS Team Puget Sound (Madigan AMC and Seattle /
  American Lake VA development team)
• UIR - User-Interface Requirements
• VA Veterans Affairs
• VistA VA primary documentation system