Electronic Medical Records and Quality Improvement V' A' Experiences

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Electronic Medical Records and Quality
ImprovementV. A. Experiences

• Brian J. Neil, MD
• Chief of Clinical Informatics
• V.A. Midwest Health Care Network, VISN 23

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Outline

• What is the VA, and where do we fit in U.S.
  Health Care?
• Transformation of V.A.
• Role of Electronic Medical Records in V.A.
• Integration of Care Pathways into the EMR
• Integration of Data Gathering Reporting Tools

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Veterans Health Administration

• Budget 35 Billion
• Medical Centers 152
• Outpatient Clinics 745
• Unique Patients Treated 6 Million
• Outpatient Visits 52 Million
• Employees 225,000
• Physicians 16,300
• Nurses (RN) 40,000
• Nurse Practitioners 3,500

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Structural Organization 22 Veterans Integrated
Service Networks VISNs are the Funding
Accountability Unit in VA

• 1995 Creating VISNs
• Objective to transform from a Hospital System
  to a Health System
• From Safety Net to Health Promotion Disease
  Prevention

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V.A. NHS Similarities

• Government funded
• Implications for funding, service planning,
  central directives, etc.
• Comprehensive Services
• (Primary Care, Specialty Care, Hospital Care,
  Community Social Care)
• Competing Centralized mandates limit
  flexibility for reorganization

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V.A. NHS Differences

• V.A.
• Integrated Primary, Specialty, and Hospital Care
• Population largely male, older, chronic
  conditions
• Eligibility rules
• Surrounded by Private Care systems

• NHS
• Silos of Primary Care, Specialty Care, Social
  Care
• Community-based population
• All eligible
• Less influence of Private Care

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Leading Change

• Establish a sense of urgency
• Create the guiding coalition
• Develop a vision and strategy
• Communicate the change vision
• Empower people to act
• Generate short term wins
• Consolidate the gains
• Anchor the change in the organizations culture
• John P. Kotter
• 1996

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What Drove the Change in Veterans Health
Administration

• A vision for change
• Structural reorganization
• Decentralization
• Evidence based medicine
• Performance measures
• Performance management
• Electronic medical record
• Establish a sense of urgency

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The Crisis

• VA not known for its Quality of Care
• Veterans were unhappy with access
• Headlines in newspapers were negative
• Congress discussed outsourcing veterans health
  care

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VA 1996

• Paper chart
• 173 Independent medical centers
• Limited access to care (_at_ 9 of those eligible)
• No clinical guidelines
• No performance measures
• Poor reputation
• Beginnings of an electronic health record

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Clinical Practice GuidelinesExpert Panels

• Hypertension
• Diabetes
• CHF
• COPD
• Coronary Artery Disease
• Immunization

• Cancer Detection colon, breast
• Smoking Cessation
• Major Depressive Disorder
• Psychosis
• Substance Abuse

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Organizing Strategy Accountability Creating
Quality Value

• VHA Value Domains
• Quality
• Access
• Satisfaction

• Functional Status
• Community Health
• Cost-Effectiveness

Value Access Quality Functional
Satisfaction Community Health COST
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Sample Performance Measures 1997

• Decrease BDOC by 19
• Increase Ambulatory Surgery by 20
• Chronic Disease Index (rollup of measures)
• Prevention Index (rollup of measures)
• Implement 12 new Clinical Practice Guidelines

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What Drove the Change

• A vision for change
• Structural reorganization
• Decentralization
• Evidence based medicine
• Performance measures
• Performance management
• Electronic medical record
• Establish a sense of urgency

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(No Transcript)
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Key Factors

• Burning Platform
• Senior Leadership Buy In/Performance Contracts
• Infrastructure (I.T. Support, Data)
• Communication Plan
• Measurement System
• Community of Practice/Champions

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Why is IT a Central Strategy?

• Quality/Safety
• 1 in 7 hospital admissions occurs because care
  providers do not have access to previous medical
  records
• 12 of physician orders are not executed as
  written
• 20 of laboratory tests are requested because
  previous studies are not accessible

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Why is IT a Central Strategy?(Continued)

• 1 in 6.5 hospitalizations complicated by drug
  error
• Cannot have integrated care without integrated
  information!
• Essential to patient centered care

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Elements Everything.

• All Outpt/Inpt Notes Consults
• Laboratory Results, EKG images
• Meds (VA Non-VA)
• Imaging Reports Images
• All Procedure Reports
• Physician Order Entry (Labs, Imaging, Pharmacy,
  Consults)
• Remote Data

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Success Factor

• Developed In-House
• Long before private sector systems developed
• Meets unique V.A. Needs
• Developed in Modules Over Time, continuously
  evolving
• Developed by Physicians for Physicians
• Organizational Structure

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My Health eVet

• Internet-based, secure Personal Health Record.
• (Available) Personalized Health Assessments
• (Available) View, retain, and update their
  personal Health Data (BP, Blood Sugar, Wt, etc.)
• (Available) Comprehensive, Personalized Health
  Education Information
• (2006) Provides veterans with copies of key parts
  of their own VA Health Record
• Activate Empower Patients as (responsible)
  partners with health care providers in achieving
  optimal health, through the sharing of actionable
  health information

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Integration of Care Pathways Posting
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Integration of Care Pathways Clinical Reminders
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Clinical Reminders

• Prompt clinical activity at the right time.
• Facilitate documentation, entry of orders for
  meds, labs, consults, etc.
• Feed data to databases.
• Reporting functionable to run reminder reports
  to generate data for process improvement

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Clinical Reminders

• Chronic Disease Management DM, Hyperlipidemias,
  CHF.
• Screening Cancers (Colorectal, Breast, Cervical,
  Prostate), Lipids, Tobacco Use, AAA
• Primary Prevention Vaccines
• Other (VA Directives)

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Integration of Care Pathways Templated Consults
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Integration of Care Pathways Meds
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Integration of Care PathwaysCase Management

• Protocols for independent prescribing and
  titration of meds for CHF, DM, COPD.
• Facility-specific hiring and supervision, some
  local variations in implementation
• Intended to reduce clinical inertia.

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Data Sources

• VA Databases are rich and retrievable
• Diagnostic codes (inpt and outpt)
• Demographics
• Labs (numeric values, completed status)
• Progress Note titles
• Meds
• Health Factors

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Data Support

• VSSC (National VA Data Analysts)
• DSS (Regional Data Analysts)
• Local Data Analysts
• Reminder Reports (National, Regional, Local, can
  drill down to individual providers)

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Implementation Challenges

• Planning, Planning, Planning
• Customization
• Expect reduced efficiency
• Leaders
• Provider buy-in vs. Provider buy-in.