health plans for enrollees and DoD plans such as TRICARE. The EHR-S associates. 2228 ..... standards organizations (ISOs). 2603. 2604. The portfolio provides ...
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45
1 Executive Summary Now, as in the past, the Veterans Health Administration (VHA) relies upon its awardwinning Electronic Health Record System (EHR-S) for support in providing Veterans with high-quality care that is effective and efficient. VHA needs a ‘next generation’ system—not incremental changes to the existing one—to anticipate the needs emerging from a range of factors that include • •
• •
Patient-centric records containing information from many sources, including VA and non-VA providers and patients themselves Changing patient profiles, for example, more cases of post-traumatic stress disorder and traumatic brain injury and changing patient expectations for ready access to health information and more convenient methods of communicating with providers Stunning advances in medicine, such as nanotechnology and genomics Increasing numbers of options for care delivery, from health care facilities to ‘care anywhere.’
This document depicts VHA’s shared vision for the next generation EHR-S, the collective discernment of desired capabilities identified through an inclusive and thoughtful planning process. To begin, VHA convened a series of stakeholder meetings with some of its ‘best and brightest.’ Small groups brainstormed about needed EHR-S capabilities that were subsequently prioritized by larger groups. Following each meeting, the shared vision document was updated to reflect new needs and posted on a web site for public (VHA) review and comment. The shared vision, while intentionally biased toward clinical needs, also addresses capabilities desired by stakeholders including allied health professionals; and staff in administration, finance, health information management, research and education. Subsequent business prioritization, requirements definition, and collaboration with the development organization will drive toward attainment of this goal. Key attributes in the shared vision of the new EHR-S are the ability to • Support enhanced communication, effectively creating care teams that include VA and non-VA providers, as well as Veterans and their family members • Provide access to information for Veterans and providers from anywhere using a variety of devices, with appropriate security and privacy rules seamlessly incorporated • Integrate prescriptive reminders and on-demand clinical decision support tools, thereby easing workflows while enhancing provider efficiency and patient safety • Offer intuitive, easy-to-navigate templates, lists, orders, and pathways, and transportable tools to support every member of the health care team
46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
•
Promote information and data re-use by supporting standardization at its core and diversity at its periphery.
VHA has been well-served by its current system. It receives higher patient satisfaction scores than other government and private health care systems. It has also greatly reduced the incidence of influenza and pneumonia among Veterans through timely reminders for inoculations, and has reduced the incidence of medication administration errors. A recent study published in Health Affairs estimated the potential cumulative benefit of health IT investments at $3.09 billion, while noting that the gross benefits were “most likely an underestimate.” 1 These remarkable results have contributed significantly to the national impetus to adopt electronic health records nationwide. To ensure that this shared vision becomes a future reality, we recommend its adoption by the Under Secretary for Health and its incorporation into VHA’s annual strategic and tactical planning sessions. We also recommend a periodic ‘refresh’ of the shared vision to ensure that it continues to anticipate and reflect accurately clinical practice needs. In this manner, the shared vision will persist beyond political and organizational change and will provide the blueprint for tomorrow’s award-winning health care system.
1
CM Bryne, LM Mercincavage, ER Pan, G Vincent, DS Johnson, B Middleton. 2010. The value from investments in health information technology at the U.S. Department of Veterans Affairs. Health Affairs 29(4):629-638; doi:10.1377/hlthaff.2010.0119
66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111
2 Document Purpose Impetus for development of the shared vision stemmed from recognition that incremental improvements to the current electronic health record system (EHR-S) will not result in the system the Veterans Health Administration (VHA) needs in the future in order to provide high-quality, effective, and efficient care. A number of earlier planning ...a living document efforts produced excellent material in specific ...a relevant guide for the future domain areas such as clinical decision support, but the findings were not formalized and presented to executive management in an actionable form. Thus, VHA entered into development of the EHR-S shared vision with the following goals in mind: •
Establish a written shared vision. There are many visions regarding the future EHR-S system throughout VHA, but none of them can truly be called shared since they typically exist only as individual mental models. Only when all stakeholders are invited to collaboratively create and refine the documented vision can the result be considered ‘shared.’
•
Make the shared vision an authoritative one. In VHA, the highest authority is represented by the Under Secretary for Health (USH). This document will be distilled into an executive decision memorandum, briefed to the Informatics and Data Management Committee (IDMC), the Health System Committee (HSC) and the National Leadership Board (NLB) prior to requesting the Under Secretary’s approval. In this way, the shared vision will garner the knowledge and support of executives and leaders throughout VHA.
•
Ensure that the vision persists. Organizational and political changes impose challenges to the execution of long-term plans. A written EHR-S vision representing the collective needs of health care practitioners dedicated to providing the best possible care to their patients and approved by the Under Secretary for Health is more likely to be achieved than one that exists informally or that does not have executive sponsorship.
•
Link the vision to development plans. The EHR-S shared vision describes a set of guiding principles and capabilities or needs that serve as a framework for the next generation system. Through adherence to the shared vision, VHA will be able to create a business roadmap that will address capability ‘chunks’ in a prioritized fashion. This will allow for incremental development/acquisition of components of the system while remaining faithful to the needs of the system users.
112 113 114 115 116 117 118
•
Sustain the shared vision. Health care, government, and technology are in a state of near-continuous change. Capabilities that are not even envisioned today may be reality in a few years. It is imperative, therefore, that the shared vision be viewed as a living document with periodic refreshes of its content. In this way, it will remain a relevant guide for the future system.
119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138
3 Changing Environment In 1995, the Veterans Health Administration (VHA) launched its “Vision for Change” and moved to the forefront in quality of care in the United States. With electronic medical records and improved efficiencies, in the late 1990s VHA went from serving over 2 million Veterans to over 4 million despite a flat budget. As a patient-centered model The largest integrated health care system in the focused on wellness and United States, in 2009 VA provided care to more disease prevention, the new than 5.7 million unique patients at more than EHR-S will engage Veterans in 1165 locations including 153 hospitals, more than monitoring and managing 780 community-based outpatient clinics their own health. (CBOCs), and 232 Vet Centers. An early leader in computerized health information systems, VA is now planning the next generation Electronic Health Record System (EHR-S), defining the capabilities that encompass all the care Veterans receive over their lifetimes. By so doing, the new EHR-S empowers VA to respond to challenges faced by health care nationally: •
139 140 141 142 143 144 145 146 147 148 149 150
•
•
2
Cost. The United States is projected to spend over $2.5 trillion on health care in 2009, or $8,160 per resident. By 2018, health care spending will be over $4.3 trillion, or $13,100 per person. 2 Coverage. In 2004, the Institute of Medicine (IOM) identified the United States as the “only wealthy, industrialized nation that does not ensure that all citizens have coverage." 3 More than 44,800 excess deaths annually in the U.S. can be attributed to the lack of health insurance. 4 Quality. The United States ranks 50th in life expectancy among the world’s countries. 5 Despite being 1st in cost and responsiveness, the U.S. health care system ranks 37th in overall performance and 72nd by overall level of health among 191 nations. 6 Compared to six other industrialized countries, the U.S. ranks last or next-to-last on five dimensions of a high performance health care
Centers for Medicare and Medicaid Services (CMS). National Health Expenditure Projections 2009-2019: Forecast summary and selected tables. http://www.cms.hhs.gov/NationalHealthExpendData/downloads/proj2009.pdf. 3 Institute of Medicine Consensus Report. 2004. Insuring America’s Health: Principles and Recommendations. 4 Wilper AP, Woolhander S, Lasser KE, et al. 2009. Health Insurance and Mortality in US Adults. American Journal of Pubic Health 99(12). DOI: 10.2105/AJPH.2009.168658 5 CIA Factbook 2009. 6 World Health Organization 2000. http://www.who.int/whr/2000/media_centre/press_release/en/
151 152 153 154 155 156 157 158 159 160
system—quality, access, efficiency, equity, and healthy lives (or outcomes)— despite having the highest level of expenditure per capita. 7 The new EHR-S is designed to strengthen the ability of VA to control costs while ensuring coverage and optimizing quality, and to do so at a time when chronic conditions and obesity are trending upward. As a patient-centered model focused on wellness and disease prevention, the new EHR-S will engage Veterans in monitoring and managing their own health. At the outset, this will increase the need for primary care services and providers. Over time, it will lead to better outcomes and more cost effective care for Veterans.
7
Davis K, Schoen C, Stremikis K. 2010. Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, 2010 Update. http://www.commonwealthfund.org/Content/Publications/FundReports/2010/Jun/Mirror-Mirror-Update.aspx?page=all
161
3.1 Veterans
162 163 164 165 166 167 168 169
Today there are more than 23 million Veterans in the United States; of these, 7.3 million were enrolled in the VA health care system as of April 2008. Of these, 43% were 65 or over, 43% were 45-64, and 14% were under 45 years of age. Any population this large is diverse. Diversity in age, gender, and demographics gives rise to changes in clinical needs for and expectations of care.
170 171 172 173 174 175 176 177 178 179 180 181
Source: 2008 Survey of Veteran Enrollees’ Health and Reliance Upon VA
8
A Changing Population Older. Between 2009 and 2018, the number of enrolled Veterans 85 or older is projected to increase 32% from 601,202 to 792,498. 9 This group accounts for the highest usage of extended and long term care services. Veterans from Korea, Vietnam, and other conflicts face the changing health risks that come with age, including 8 9
http://www.va.gov/HEALTHPOLICYPLANNING/SoE2008/2008_SoE_Report.pdf http://www.va.gov/op3/Docs/StrategicPlanning/VA_2010_2014_Strategic_Plan.pdf
182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228
increased incidence of chronic conditions such as diabetes and prostate cancer. As the older generations pass away, the Gulf War population will dynamically shift the demographics back to a younger age with war specific injuries and needs. Designed to accommodate ongoing changes, the EHR-S offers the fluid capabilities that will be required to meet their needs. More rural. In contrast to the general population, only 20% of whom live in rural areas, significant numbers of Veterans live in rural areas. In 2006, 36% of Veterans enrolled in VA health care resided in rural areas and an additional 1.5% resided in areas considered ‘highly rural.’ For Veterans far from urban areas, access to VA health services requires new ways of accessing care, such as VA telehealth programs and in some cases referrals outside VA. All such services are facilitated by the ability of the EHR-S to provide a single and complete record for every Veteran VA serves. More from current conflicts. Today’s soldier is tomorrow’s Veteran, and VA is already experiencing an influx of Veterans from current conflicts. Since 2002, more than 1,109,200 Veterans of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) have left active duty or the reserves and become eligible for VA health care. Almost half of these, 552,135 have received VA health care. For this generation of Veterans, re-entry into civilian life poses many challenges, many of them traditional, some new. Each conflict has had its own characteristic injuries. Increasingly, patients For Korea it was frost bite, for Vietnam it was Agent expect care to be delivered Orange, for OEF/OIF it is traumatic brain injuries in a coordinated, seamless (TBIs) and other injuries resulting from improvised explosive devices (IEDs). fashion whether provided by VA or non-VA. They More female. Women make up 11.3% of OEF/OIF expect providers to look at Veterans. Of these, 49.7% have enrolled with VA them in a holistic fashion health care. Of those enrolled, 47.8% have used VA rather than as a series of health care 11 or more times. More women discrete body parts. OEF/OIF Veterans using VA care are under 30 years of age (47.3%) than are their male counterparts (43.1%). In 2009, women comprised 7.5% of the total Veteran population and nearly 5.5% of all Veterans who use VA health care services. By 2020, female Veterans are expected to constitute at least 10% of the total Veteran population and 9.5% of VA patients. Today, women Veterans are younger (average age 47) than male Veterans (average age 61), and they expect VA to provide the full range of services they need, including breast, obstetric, and gynecological care. Changing Clinical Needs Many of the changes in clinical needs and expectations are associated with age, gender, and demographics. Others are associated with the nature of exposures or wounds characteristic of the conflicts in which Veterans served. This poses challenges unique to VA.
229 230 231 232 233 234 235 236
237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265
Different wounds. Advances in military medicine and, more recently, the widespread use of body armor and helmets have reduced mortality rates among service members. They have also changed the nature of injuries suffered by OEF/OIF Veterans. As of June 30, 2010, the VA reported 1,024 OEF/OIF amputees. A recent study shows OEF/OIF Veterans less likely than Veterans of World War II and Vietnam to suffer thoracic injuries or gunshot injuries and more likely to have injuries to the head and neck region and explosion related injuries, as shown in Table 1. Thoracic injuries Injuries to head and neck region Gunshot injuries Explosion related injuries
World War II 13.9% 21.0% 27% 73%
Vietnam 13.4% 16.0% 35% 65%
OEF/OIF 5.9% 30.0% 19% 81%
Table 1. Wounding Patterns and Mechanisms of Combat Wounds Source: KH Taber and RA Hurley, “OEF/OIF Deployment-Related Traumatic Brain Injury,” PTSD Research Quarterly 21(1). Winter 2010.
Traumatic brain injuries. Trauma Registry Data from OIF show 88% of combat-related TBIs involved exposure to explosions, including IEDs and other mechanisms. 10 Among returning soldiers from OIF treated at Walter Reed, almost 60% of those injured by an explosion had a TBI (44% mild, 56% moderate-severe). 11 These wounds often result in multiple severe injuries and disabilities requiring extended and highly specialized care, both mental and physical. Polytrauma. From March 2003 through March 2010, VA’s four main polytrauma rehabilitation centers treated nearly 1,800 patients with severe multiple injuries. The vast majority of these patients have been on active duty at the time of admission, as the major cause of injury has been trauma sustained in combat. Their injuries involve more than one physical region or organ system, most notably TBI but also The ability to integrate data amputations, fractures, burns, hearing loss, visual from Veterans’ personal impairment, and post traumatic stress disorder (PTSD). health records into VA’s EHR enriches the evidence Hazardous exposures. VA recognizes hazardous exposures to Agent Orange and other herbicides are base used to treat associated with birth defects in children of Vietnam individual patients and to Veterans, with certain cancers, and other health support system-wide problems. VA continues to update the list of illnesses understanding of many presumed associated with service in Vietnam and in illnesses. subsequent conflicts.
10
Galarneau, M.R., Woodruff, S.I., Dye, J.L., Mohrle, C.R., Wade, A.L. 2008. Traumatic brain injury during Operation Iraqi Freedom: Findings from the United States Navy-Marin Corps Combat Trauma Registry. Journal of Neurosurgery, 108, 950-957. 11 Okie, S. 2005. Traumatic brain injury in the war zone. New England Journal of Medicine, 352, 2043-2047.
266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302
As many as 250,000 Gulf War Veterans suffer from multi-symptom illnesses. 12 Often attributed to toxic exposures and known as Gulf War Syndrome, they include fatigue, fibromyalgia, irritable bowel, and a host of other symptoms associated with undiagnosed illness. With so many Veterans affected, a common exposure appears unlikely. Overall extreme stress on the psyche has also been identified as a potential contributing or exacerbating factor. While experts agree the cause may never be found, 13 these medically unexplained, diffuse clusters of symptoms are now presumed to be associated with military service. For OEF/OIF Veterans, who are at risk of exposure to burn pits, depleted uranium, toxic embedded fragments, and other environmental hazards, 14 the new EHR-S is essential to diagnosing exposurerelated illnesses. The ability to integrate data from Veterans’ personal health records into VA’s EHR enriches the evidence base used to treat individual patients and to support system-wide understanding of these and other perplexing illnesses.
Treating complex, chronic conditions generates significant amounts of data, from many different providers, that must be maintained and watched for trends, both to care for the individual patient and to improve the quality of care delivered to others.
Mental health. In 2006, more than 1.5 million of the 5.5 million Veterans seen in VA had a mental health diagnosis, a 31% increase since 2004. 15 This trend continues. The Institute of Medicine has identified PTSD as ‘clearly caused’ by the Gulf War, and the number of OEF/OIF Veterans seeking treatment for PTSD jumped almost 70% in the 12 months ending June 30, 2007. Of 289,328 OEF/OIF Veterans seen at VA facilities from 2002 through 2008, 37% received mental health diagnoses; 22% were diagnosed with PTSD and 17% with depression. 16 The potential impacts of mental health issues loom large for active duty Veterans returning home to civilian life and pose a large challenge for VHA. Veterans under 25 have higher rates of PTSD and substance abuse than Veterans over 40. Most mental health diagnoses are not made in the Veteran’s first year at VHA, but several years after. 17 Among Veterans with PTSD, substance abuse involving opioids, benzodiazepines, and alcohol as a means to deal with their trauma is a common mental health co-morbidity.
12
Institute of Medicine. April 9, 2010. Gulf War Veterans’ Illnesses: Institute of Medicine Report on Gulf War (1990-1991) and Health. 13 www.publichealth.va.gov/exposures/gulfwar/associated_illnesses.asp. Reviewed/Updated Date: July 20, 2010. 14 www.publichealth.va.gov/exposures/oefoif/index.asp. Reviewed/Updated Date: July 22, 2010. 15 Seal, K.H., et al. 2007. “Bringing the war back home: Mental health disorders among 103,788 Veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs Facilities.” Archives of Internal Medicine, 167(5), 476-482. 16 KH Seal et al. 2009. “Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, 2002-2008.” American Journal of Public Health 99(9), 1651-1658 17 Seal et al. 2009.
303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345
VA providers are now seeing increases in substance abuse with the return of OEF/OIF Veterans, some with chronic pain from physical injuries, others with psychological pain. The toll is high for Veterans and their families, stressing The new EHR-S meets the marriages and other relationships. More than expectations of Veterans 131,000 Veterans are homeless on any given night, and an average of 18 Veterans die by and their families for suicide every day. personalized health information addressing The illnesses associated with hazardous their individual exposures and the wounds characteristic of circumstances and health today’s conflicts are much more complex than a status. single injury. They are also lifelong conditions. Treating these complex, chronic conditions generates significant amounts of data, from many different providers, that must be maintained and watched for trends, both to care for the individual patient and to improve the quality of care delivered to others. Increasingly, patients expect care to be delivered in a coordinated, seamless fashion whether provided by VA or non-VA. They expect providers to look at them in a holistic fashion rather than as a series of discrete body parts. Changing Expectations and the EHR-S Since 2003, a growing number of Veterans and their families have come to rely upon My HealtheVet, a free Personal Health Record (PHR) on VA’s e-health website, to access information and become more active partners in their health care. Every year VA has added to the services this PHR offers; every year more Veterans have made use of it. More mature Veteran generations have joined the new generation of OEF/OIF Veterans that grew up with cell phones and computers in viewing the internet as a primary information source and expecting the convenience and rapid responses it makes possible. The new EHR-S meets the expectations of Veterans and their families for personalized health information addressing their individual circumstances and health status. The new EHR-S enables Veterans to maintain their own personal health records, entering in a wide range of information, from family histories to wellness regimens and readings from home medical devices used to manage diabetes, heart failure, pulmonary diseases and other chronic conditions. This is much more than a convenience. It improves disease management for patients and productivity for providers while, at the same time, it improves disease surveillance and detects emerging symptoms in Veterans individually and collectively.
346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387
3.2 Care Anywhere The transformative power of the new EHR-S comes from its ability to support care anywhere, not just in VA facilities and community-based clinics, but anywhere healthrelated information is collected—at home, a local minute clinic, a private practice physician’s office, a health club, drugstore, or grocery store. For one Veteran, this includes blood sugar readings taken several times a day at home; The transformative power for another, home blood pressure readings or a flu of the new EHR-S comes shot at the grocery store pharmacy. from its ability to support care anywhere, not just in These data and much more all become part of the VA facilities and Veteran’s record in the EHR-S, thanks to the community-based clinics, evolving Nationwide Health Information Network but anywhere health(NHIN). An initiative involving both private and related information is public sectors, including VA, the NHIN is being collected—at home, a local developed to provide a secure health information minute clinic, a private exchange infrastructure, complete with rigorous practice physician’s office, a privacy and confidentiality rules to protect patients and their families. health club, drugstore, or grocery store. By supporting the transition of health applications onto mobile technologies such as cell phones and other handheld devices, the NHIN is revolutionizing services for Veterans. The availability and coverage of wireless technologies and the increase in social networking are changing Veterans’ expectations about the way in which care is delivered. ‘Virtual’ channels and partnerships extend the EHR-S to reach Veterans wherever they may be. Even those in remote rural areas can access the care they need where they need it when they need it. According to the Congressional Budget Office, Veterans receive only a portion of their care from VA. Veterans with service-connected disabilities receive between 33% and 47% from VA, Veterans who are housebound about 49%, and those who qualify because of low income about 43%. 18 They receive the balance from other sources, including Medicare, Medicaid, private health insurance, the military health system, and public hospitals. The NHIN provides the linkages that allow data from Veterans’ encounters with non-VA providers to become part of VA’s EHR-S, creating the comprehensive records critical to patient-centered care. VA experience with its PHR, MyHealtheVet, is guiding efforts to use smartphones and associated social networking applications like Twitter and Facebook. Wireless access to secure patient portals and from there into the EHR-S strengthens communication 18
Congressional Budget Office. 2007. The Health Care System for Veteran s: An Interim Report. www.cbo.gov/ftpdocs/88xx/doc8892/MainText.3.1.shtml. Accessed 10/22/2010.
388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433
among patients and providers. Designed to educate and empower patients and their families, the new EHR-S enhances their care experience. As a holistic, Veterancentered system, it eases access and coordination of care, while it improves effectiveness and health outcomes. The new EHR-S integrates the use of telehealth, teleradiology, and other emerging technologies into a patient-centered health care model to ensure that all enrolled Veterans get the most out of their VA health care. In addition to enhanced support for complicated hospital-based interventions, the EHR-S supports primary and specialty services in other contexts, including community-based outpatient clinics and even the Veteran’s home. For mental health needs, it links to virtual services offering consultations on real-time clinical video-conferences through tele-mental health. For Veterans in the midst of a mental health crisis, support is available via the suicide hotline 24 hours a day.
The Nationwide Health Information Network provides the linkages that allow data from Veterans’ encounters with non-VA providers to become part of VA’s EHR-S, creating the comprehensive records critical to patient-centered care.
The new EHR-S delivers ‘care anywhere’ by exploiting the capabilities provided by videoconferencing, the Internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications. Integrated into the EHR-S, these emerging health technologies allow patients with chronic diseases such as diabetes, heart failure, and chronic pulmonary disease to be monitored at home. This reduces hospital admissions, clinic visits, and emergency room visits. Elderly or disabled patients can stay in their homes longer and receive cutting-edge specialty care even in sparsely populated areas. This model of care is especially beneficial for the 2 to 3% of patients who, in part because they frequently visit hospitals and outpatient clinics, account for approximately 30% of health care costs. Building on VA’s successful use of telemedicine, the new EHR-S focuses on prioritized Veteran patient needs and coordinates services across the continuum of care. Ongoing increases in VA’s telehealth capacity accommodate the expansion of telehealth services to reach Veterans requiring specialty care or simply living in remote rural areas. Under treatment for chronic back problems, 45-year-old Maria Gonzales wakes up at 6:45 a.m. in severe pain. At her computer, she logs in to her PHR and selects the Primary Care icon in the Virtual Health Clinic. A telehealth triage nurse appears on the screen, where she does a preliminary assessment and takes vitals by asking Gonzales to place her palm on a biometric sensor on the computer screen. After reviewing Gonzales’ EHR (where the vitals appear), the nurse alerts the patient’s primary care physician. In a few minutes, the doctor appears on Gonzales’ computer screen, reviews her symptoms and health history, and examines her range of movement using the built-in webcam in the system. Together doctor and patient decide to try physical therapy and yoga to see if the symptoms abate. The holographic physical therapist and yoga instructor do not require Gonzales to leave her home in rural Montana; virtual sessions are just a touch away.
434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450
With an expanding array of technologies to facilitate access and deliver services, the new EHR-S supports the right care in the right place at the right time. For the Veteran who is elderly, disabled, or living in a remote area, these capabilities help prolong the capacity for independent living. For all Veterans, these capabilities provide access to the care they need. Within VA’s new patient-centered model for teambased clinical practice, the new EHR-S supports patient self-management, advising the Veteran what options are available and how to connect with the best available care, anywhere. “No decision will be made about me without me.”
The new EHR-S supports patient self-management, advising the Veteran what options are available and how to connect with the best available care, anywhere. “No decision will be made about me without me.”
451
3.3 Clinical Practice
452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495
The new EHR-S is essential to the clinical care Veterans receive now and will receive in the future. It supports VA providers and staff as they expand their roles into a fully integrated health care team, a team that includes the Veteran, to ensure care is delivered in an individualized and focused manner. As a system, it facilitates workflow while promoting evidence-based practices and measurably better outcomes, continuing to advance VA health care and achieve new To optimize workflow, the benchmarks for excellence in health care in the new EHR-S acquires United States. comprehensive data as an integral part of the work Workflow-driven, the new EHR-S eases the process without adding to provider’s tasks. Data are acquired as an integral the provider’s workload, part of the work process, without undue burden or data that supports both re-work. Knowledge-driven, the EHR-S optimizes evidence-based care and the Veteran’s care. It gives providers access to evidence-based state-of-the-art advances, while it gathers data that management. support the creation of new knowledge and helps integrate new findings into clinical medicine. For example, research in the area of personalized medicine is developing safer, more effective treatments based on new knowledge about the role of genes in health and disease. Genomic analysis has already provided tremendous insights into the origins of diseases that affect large numbers of Veterans, such as diabetes and cancer. The goal is to support medical care that can be personalized to the genetic makeup of individual Veterans. Genomic analysis using DNA from cheek swabs or blood tests can help to predict an individual Veteran’s response to certain drug treatments and pinpoint the proper dose. In transitioning from inpatient to outpatient care, VA has relied on innovative technology solutions. The new EHR-S leads to the next step, from episodic to longitudinal care that is truly patient-centered. To optimize workflow, it acquires comprehensive data as an integral part of the work process without adding to the provider’s workload, data that supports both evidence-based care and evidence-based management. To better coordinate patient care, it offers real-time visibility into the system, transparent across the enterprise, minimizing delays and easing handoffs. Integrated into the EHR-S, these capabilities support clinical practice as it accommodates evolving patient needs and state-of-the-art advances in clinical knowledge. As Veterans age and new Veterans come to VA for care, their needs and their expectations change. So too do standards and models of care and the technologies that support clinical practice.
496 497 498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541
56-year-old George Brown comes to the VA primary care clinic for a routine appointment. At the checkin kiosk, he swipes his VA Card, enters his password, and verifies his contact information. The kiosk prompts Brown to review his medication profile. It shows pictures of the tablets he is prescribed and asks how he takes the medication. When and how often? Whole pill or half? Because he is being treated for congestive heart failure, he is asked whether he has a scale at home and weighs himself daily, and queried about his salt intake. Does he eat fast foods or processed foods? When he is done, the kiosk tells him the nurse will call him in 5 minutes, based on real-time data for nursing workflow. When information from the kiosk appears on the nurse’s wireless device, she calls the patient in, takes vitals, checks clinical reminders, and reviews data gathered at the kiosk. Using her wireless device, she confirms the provider is available and takes Brown to meet the provider in the exam room, information in hand.
Patient-Centered Primary Care VA’s new model for care is patient centered. It involves a team of health professionals, led by the Veteran’s primary care provider. Together the primary care team serves as the Veteran’s first contact for care, and coordinates care delivered by other VA and non-VA providers. This ensures that Veterans receive high quality primary care that results in better health outcomes, improved patient experience, and more efficient use of resources.
Advanced analytical techniques in the EHR-S help VA to eliminate variability in the system, ensuring that every Veteran receives the best care anywhere.
The EHR-S creates a record that integrates all the data on all the care a Veteran receives, in VA or elsewhere, over the Veteran’s lifetime, creating a comprehensive medical record. Health Maintenance and Disease Prevention Because chronic conditions are increasingly prevalent in the Veteran population, VA’s patient inclusive health model stresses health maintenance and disease prevention. Clinical interventions are seamlessly integrated across the continuum of health care and delivered using the modality chosen in consultation with the Veteran. The EHR-S routinely scans lab results to identify Veterans at risk of chronic conditions and alerts their care team to consider evidence-based interventions. For example, Veterans with diabetes can upload readings from their home glucometers using VA’s PHR or their smartphone for review by their care team and take timely action to address problematic trends. The increased involvement of the Veteran improves outcomes, while changes to the clinical workflow are supported by the EHR-S which integrates the Veteran’s input into the record, analyzes it, and notifies the appropriate provider.
542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587
Specialty Care Communication capabilities When Veterans require specialty care, the care integrated into the EHR-S team arranges for those services to be provided by allow VA to be a navigator VA or outside VA, if the Veteran lives in a rural and coach for all enrolled area or there is a shortage of providers in a given Veterans and their family specialty. Inside the VA system, the care team uses the EHR-S to coordinate services and ensure members, ensuring they timely access for the Veteran. Outside VA, the have the best information EHR-S links to providers using the Nationwide available to make informed Health Information Network (NHIN). In both choices about their health. instances, specialty care interfaces with primary care to become team-based and patient-centered, ensuring that Veterans receive high quality care wherever it is delivered and a complete record of care is seamlessly maintained by integrating the care received as part of VA’s patient centered EHR-S, to guide and inform other care decisions. When Veterans’ needs dictate new programs, VA is able to identify those needs, develop new programs, and share them across the VA system, as it is now doing for Traumatic Brain Injuries (TBI) and polytrauma patients, signature injuries of the conflicts in Iraq and Afghanistan. Mental Health Care Patient-centered care requires meaningful choices among mental health treatments, with access to services eased by smart phones, social networking, videoconferencing, and other new technologies. These treatments balance biological and biomedical approaches with psychological and psychosocial strategies. The comprehensive, integrated data available in the EHR-S supports these balanced approaches and the increased use of psychological and behavioral interventions for Increased monitoring of problems like pain and insomnia. Increased mental health treatments monitoring of mental health treatments and their and their effectiveness, effectiveness, supported by the EHR-S, allows for ongoing improvements in the quality and efficiency supported by the EHR-S, of these critically needed services. allows for ongoing improvements in the Long Term Care quality and efficiency of these critically needed Another important component of fully integrated services. care for Veterans is long term care. Nearly half of VA enrollees are 65 or older, with more than a million over age 85. Younger enrollees include survivors of critical injuries from the conflicts in Iraq and Afghanistan with resultant chronic disabilities. Innovative programs using the EHRS and telehealth capabilities enhance the availability of home and community-based care services and speed the transition of care to those settings. Increasingly patient-
588 589 590 591 592 593 594 595 596 597 598 599 600 601
centered services support independence-promoting alternatives to nursing home care. Institutional care is reserved for situations in which the Veteran cannot safely remain at home.
602 603 604 605 606 607 608
Advanced analytical techniques in the EHR-S help VA to eliminate variability in the system, ensuring that every Veteran receives the best care anywhere. Communication capabilities integrated into the EHR-S allow VA to be a navigator and coach for all enrolled Veterans and their family members, ensuring they have the best information available to make informed choices about their health. Better outcomes result, and VA becomes the national benchmark for patient satisfaction and for quality, safety, and transparency of health care and advice.
609
Eighty- three year-old Mr. Calub has granted his daughter permission to access his medical records and help monitor his care from her home 150 miles away. Enrolled in an outpatient program to help him remember his medications, he uses a mobile device that alerts him when it is time for his insulin and creates a medication administration log when he presses a button on the device. When he does not sign off on his last three insulin doses, the system alerts his daughter, who calls her father and discovers he is not feeling well. When she contacts his care team electronically, the case manager helps get Mr. Calub in to the hospital for evaluation and treatment.
Less Variability, Better Outcomes
610
3.4 VA Partners
611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649
VA is an active partner with other government and non-government entities in a wide range of efforts that share information about Veteran patients, while complying with safeguards protecting privacy and confidentiality. Because today’s service member is tomorrow’s Veteran, many of these exchanges involve the Department of Defense (DoD).
We need your help to shift the focus for this section from the present to the future .
VA is partnering with DoD to share patient data from their individual electronic health record systems. Using the Nationwide Health Information Network (NHIN), they are linking to enable the delivery of the entire military treatment record to VA, speeding disability determinations and creating Virtual Lifetime Electronic Records (VLERs) for all Veterans spanning the continuum of care. With more than 80% of the country’s electronic records shared between DoD and VA 19, this is the responsibility of the two Departments’ Interagency Program Office. DoD/VA Bidirectional Health Information Exchange As of December 2009: More than 3.5 million shared patients 1st quarter FY 2010: Average of 60,500 inquiries per week Source: Flagship Report. http://open.dodlive.mil/open-government-plan/flagship/
VA collaborates with the Social Security Administration (SSA) to expedite wounded warriors’ disability applications for Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI), benefits that differ from those offered by VA. This collaboration involves including functional assessment data in the Veteran’s record and making that data part of the EHR-S that can be exchanged over the NHIN. Because over half of the care service members and Veterans receive is provided by the private sector, 20 VA is partnering with permission from its patients and private health care providers in San Diego, CA, Indianapolis, IN, and the Tidewater Virginia area to share records. For Veterans covered under private plans who receive VA care for conditions linked to military service, this provides a seamless transition and extends the 19
In Depth: Flagship Init. We’ve updated our Open Government Plan…. March 8, 2010. http://open.dodlive.mil/open-government-plan/flagship/ 20 Dr. Stephen Ondra, senior policy adviser on health affairs for VA, quoted by Keith Darce in “Medical breakthrough: VA, Kaiser to share records.” Accessed 10/22/2010 at ww.signonsandiego.com/news/2010/jan/06/a-medical-breakthrough-va-kaiser-to-share-records
650 651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 673 674 675 676 677 678 679 680 681 682 683 684 685 686 687 688
concept of team-based, patient-centered care. As a pilot, DoD joined VA in building on this partnership in Virginia. VA partners with the Centers for Disease Control and Prevention (CDC) in a number of programs that involve the sharing of patient data. Along with DoD, over 570 private sector hospitals, and major laboratory systems, VA contributes de-identified patient data to BioSense, a nationwide biosurveillance system. As a member of CDC’s Public Health Information Network (PHIN) Communities of Practice Program, VA works to ensure that the NHIN provides a collaborative framework for sharing health records. VA collaborates with the Food and Drug Administration (FDA), sharing patient data to improve drug safety. VA data assists in a number of studies; for example, one evaluating psychiatric events in patients treated with varenicline, another assessing the risk of statins and Amyotrophic Lateral Sclerosis or ALS (commonly known as Lou Gehrig’s disease), and a third looking at risks of bisphosphonates, atrial fibrillation, and severe myalgias/myositis. VA also collaborates with the Department of Health and Human Services (HHS) and the Indian Health Service (IHS), sharing patient information via the EHR-S to enhance access to health care services and improve the quality of care for American Indian and Alaska native Veterans. VA's medical and dental program is conducted primarily through affiliations with University Schools of Medicine and also with teaching hospitals. In 2010, 124 of VA’s 153 medical centers and two of six independent outpatient clinics offer graduate medical education (GME) or undergraduate medical education through affiliations with 112 of the nation's 131 allopathic medical schools and 15 of the 26 osteopathic medical schools. Through these partnerships, over 36,000 physician residents and about 25,000 medical students received some of their training in VA facilities each year. 21 Accounting for approximately 9% of U.S. physician residents, VA supports over 10,000 physician and over 360 dental resident positions in over 2,000 residency programs accredited in the name of its university or teaching hospital partners. Over 65% of U.S. physicians have had some training in a VA facility. For them all, the EHR-S was an integral part of their professional education.
21
http://www.va.gov/oaa/GME_default.asp
689 690 691 692 693 694 695 696 697 698 699 700 701 702 703 704 705 706 707 708 709 710 711 712 713 714 715 716 717 718 719 720 721 722 723 724 725
3.5 Government We need your help to shift the focus for this section from the present to the future . American Reinvestment and Recovery Act (ARRA) funding totaling $1.8 billion is being used to modernize and replace VA medical facilities, make improvements at national cemeteries, and award grants to states for Veterans homes. To help Veterans access their care, ARRA projects at VA medical facilities are upgrading nearly 14,000 inpatient bed spaces and renovating 16 pharmacies. More than 145,400 clinical improvement projects, some with multiple exam rooms, are underway. 22 In 2009, the President announced that DoD and VA had taken the first step in creating a Joint Virtual Lifetime Electronic Record (VLER) and that the Senate passed budget included funding to support this concept. For VA, this included dramatically increased funding for Veterans health care and investment in better technology to deliver services and benefits. 23 The Office of the National Coordinator for Health Information Technology (ONC) coordinates a variety of programs to implement the Health Information Technology for Economic and Clinical Health (HITECH) Act enacted as part of ARRA. These and other initiatives support efforts to facilitate nationwide adoption of health information technology. Three of these are of special relevance to VA’s EHR-S: • The Nationwide Health Information Network (NHIN), a collection of standards, protocols, legal agreements, specifications, and services to enable secure health information exchange • The Clinical Decision Support (CDS) and the CDS Collaboratory, an initiative to provide clinicians, staff, patients, or other individuals with knowledge and personspecific information, intelligently filtered or presented at appropriate times, to enhance health and health care • The Federal Health Architecture, an e-government line of business initiative to increase efficiency and effectiveness in all government operations. 24
22
News release. October 15, 2010. VA tops $1B mark in Recovery Act distributions. http://www.va.gov/opa/pressrel/pressrelease.cfm?id=1982 23 Press release. April 2, 2009. President Obama announces the creation of a joint virtual lifetime electronic record taking care of America’s greatest strategic asset and improving the health care system for America’s veterans. http://www.whitehouse.gov/the-press-office/president-obama-announces-creation-a-joint-virtual-lifetimeelectronic-record 24 ONC Initiatives. http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__onc_initiatives/1497
726
3.6 Information Management
727 728 729 730 731 732 733 734 735 736 737 738 739 740 741 742 743 744 745 746 747 748 749 750 751 752 753 754 755 756 757 758 759 760 761 762 763 764 765 766 767 768 769
Changes in information management stem from changes in the global environment. In health care, Veterans expect care to be the heightened expectations of patients, health care available at times and places organizations, providers, and society as a whole convenient for them, and they are driving collective change. Their demands are want care without having to for high-quality, on-demand information to guide repeat basic demographic clinical decision making and related functions. As information to every new the frontline tool for accessing, using, and gathering information, the new EHR-S Is designed to respond provider they see. The EHR-S to the challenges facing information management helps meet these expectations by by sharing information among • Supporting the management of knowledge providers, across multiple as well as patient and population data settings in the VA and in even • Accommodating both primary and secondary the private sector, using an uses of data array of technologies, from • Leveraging the capabilities provided by smart phones to the Nationwide structured or encoded health care data and Health Information Network. the inclusion of images, signals, and most recently genomic information. In addition, the new EHR-S offers features and functions that Veterans, VA providers, and society as a whole increasingly expect information management to provide. As patients, Veterans expect high quality care, and they expect providers to be aware of best practices and the nuances of status and treatment. Veterans expect care to be available at times and places convenient for them, and they want care without having to repeat basic demographic information to every new provider they see. The EHR-S helps meet these expectations by sharing information among providers, across multiple settings in the VA and in even the private sector, using an array of technologies. In combination with patients’ own personal health records (PHRs), it allows for uploading patient-entered data and downloading lab results and other clinical information from their providers. Long recognized for the success of the Computerized Patient Record System (CPRS), VA continues to fuel expectations by computerizing what was previously manual, from complex acts like requiring a log of all medical record access to simple requests like insisting on 0% unsigned notes. Workflow-driven, the new EHR-S offers the flexibility to address underlying process challenges and unintended consequences that may result. The availability of more data in electronic form has also led to expectations for meeting administrative and financial information needs as a by-product of clinical uses of information systems. Standards-based for interoperability, the EHR-S brings the needs and requirements of the clinical, administrative, and financial domains into alignment.
770 771 772 773 774 775 776 777 778 779 780 781 782 783 784 785 786 787 788 789 790 791 792 793 794 795 796 797 798 799 800 801 802 803 804 805 806 807 808 809 810 811 812 813 814 815
The use of standard terminologies resolves historic tensions regarding different ways of representing data (for example, free text for clinical expressiveness vs. diagnostic and procedure codes for billing purposes) and creates the foundation for sharing information across VA and beyond. As an organization, VA has heightened expectations for population health, quality measurement, and clinically-focused analytics. The new EHR-S offers the information management capabilities to meet these needs, including access to an expanding data repository and to an assortment of tools appropriate for Standards-based for clinicians, clinical program administrators, and interoperability, the EHR-S other VA professionals. Importantly, the new EHRbrings the needs and S includes seamlessly integrated security and requirements of the clinical, privacy systems that provide the framework and administrative, and services to meet organizational demands for both financial domains into security and openness (in terms of functionality alignment. and accessibility). As workloads and patient complexity have grown and provider time slots have shrunk, clinicians have come to expect smarter, more assistive systems. These expectations are growing gradually as more types of work are shifted from nurses and other support staff to clinicians themselves, as in the case of provider order entry. Over time, providers (and patients) have come to expect patientcentered integration of data across sources of care, which the new EHR-S provides. This has a major impact on information management, necessitating policy changes to address practice changes induced by shared care, for example, discontinuing medications, reviewing medications for conditions outside one’s specialty, and canceling redundant orders. Changes in medicine itself bring new and increasingly complex types of data. Personalized medicine takes into account the individual Veteran’s genetic make up and offers new, more effective treatments. It also requires a patient record that includes genomic data. This has implications for the new EHR-S, changing both the nature of data (broader than simply text) and mechanisms for delivery of data (screen size, computing power, graphical and color capabilities, etc.). The heightened expectations of society as a whole are a relatively recent phenomenon, although the underlying desire (and dissatisfaction) has been simmering for years. Today this takes the form of implicit expectations for provider participation in the NHIN, for standardization in the industry, and for provider and organizational use of systems that support those standards. There is also an expectation that information management can support both patient-centered and population-based care. The challenge is to reconcile information interchange requirements with intensifying demands for sharing data and documents that are readable across systems. To this end, the new EHR-S is standards-based, and VA is an active participant in the international standards organizations working in this demanding and evolving arena.
816 817 818 819 820 821 822 823 824 825 826 827
Today VA’s clinical and information technology communities continue their collaboration in an environment that is ever more sophisticated. Together they are • • • •
Moving beyond a computerized version of the paper chart to a full and complete lifelong electronic health record for each Veteran Taking innovative approaches to comprehension, visualization, and interpretation of data Eliminating ‘administrative’ and ‘clinical’ silos and bridging the barriers across settings in VA and other sectors Creating a comprehensive system for transparent health information exchange that supports the entire health care enterprise.
828 829 830 831 832 833 834 835 836 837 838 839 840 841 842 843 844 845 846 847 848 849 850 851 852 853 854 855 856 857 858 859 860 861 862 863 864 865 866 867 868 869 870 871 872 873
3.7 Technology Over the past few years, policy makers have grown increasingly aware of the effect government investment in information technology at the Department of Veterans Affairs is having on US health care. VA health care has undergone a well-publicized transformation in the last 15 years. VA is recognized as the industry leader in quality, safety, efficiency, and patient satisfaction. There are a number of reasons behind this turnaround including visionary leadership, dedicated workforce, and a more transparent approach to quality improvement. It is hard to imagine, though, a more important factor in the VA success story than information technology.
Just as the electronic health record system enables a provider to learn a patient’s history by viewing data entered hundreds of miles away, the personal health record gives Veterans access to information once obtained only by talking to the doctor during an appointment or waiting in a queue at the release of information office.
The next generation of the Electronic Health Record System (EHR-S) continues this transformation. Clinical workstations, tablet PCs, and smartphones give providers ready access to a range of information, presented to them in the form of order checks, allergy checks, and decision rules that help guide them to the best treatment options. Safety checks are incorporated into high-risk processes like medication administration. Patient satisfaction is greatly enhanced by supporting Veterans’ access to services in a growing number of settings. Clearly, emerging technologies are changing the way VA provides patient care. Widely available, personal health records (PHRs) allow patients to store their own health information. Growth for this purpose, even for Google’s and Microsoft’s internetbased offerings, has been unimpressive. It seems patients are not attracted to a PHR just to self-enter their medical history. Patients are attracted to use of a PHR if it provides: • • •
Access to certain information in their EHR (appointments, wellness reminders, etc.) Access to their health care team through secure messaging Access to online transactions (prescription refills,).
Veterans use the PHR to find information about services and information, including diagnosis-specific educational materials, 24 hours a day. Just as the new EHR-S enables a provider to learn a patient’s history by viewing data entered hundreds of miles away, the PHR gives Veterans access to information once obtained only by talking to the doctor during an appointment or waiting in a queue at the release of information office.
874 875 876 877 878 879 880 881 882 883 884 885 886 887 888 889 890 891 892 893 894 895 896 897 898 899 900 901 902 903 904 905 906 907 908 909 910 911 912 913 914 915
Familiar fixtures at US airports, stand-alone interactive kiosks in hospital lobbies and clinic waiting rooms speed appointment check-in, collecting required patient information and verifying coverage. They improve patient safety by displaying pictures of medications and asking patients to verify what drugs and dosages they are actually taking. Like PHRs, kiosks have the greatest potential for change when they improve the ability of Veterans to perform self-care and become less passive, more active participants on their own health care team. Embedded in the EHR-S, context-sensitive information retrieval helps providers link to medical knowledge quickly and easily, reducing the risk of clinical errors and practice variation. One ‘infobutton’ medication application answered providers’ queries 84% of the time and altered patient care decisions 15% of the time, in an average session only 21 seconds long. 25 Clearly infobuttons have the potential to answer provider questions using data in the EHR-S augmented by web-based information resources.
Embedded in the EHR-S, context-sensitive information retrieval helps providers link to medical knowledge quickly and easily, reducing the risk of clinical errors and practice variation.
When the clinician uses the EHR-S to assemble and integrate relevant data for a given clinical scenario, context-specific technology is available to narrow the range of important treatment questions to fit the unique circumstance of the case. Automating these processes results in faster and more informed decision-making and facilitates the completion of tasks needed for optimal patient outcomes. Other emerging technologies, already here in some settings, support a range of functions, all of them linked to the EHR-S. ‘Smartboards’ activitated by radio frequency identification (RFID) tags worn by hospital staff can display information relevant to whomever enters a patient’s room—vitals and lab values for the clinician, scheduled patient care activities for the nurse. Non-invasive ‘body sensing blankets’ monitor the patient’s health statistics, and ‘smart beds’ track the patient’s weight and position, inputting data into the EHR while easing clinical workflow and improving the patient experience. Some are more futuristic. For example, a life-sized wall display allows clinicians to visualize their patient’s EHR in the context of an avatar ‘body’ that can trigger a search of the patient’s records and retrieval of relevant information. Life-sized displays of the patient’s EHR help clinicians visualize and explain processes and medical procedures more easily and more understandably to patients.
25
SM Maviglia, CS Yoon, DW Bates, G Kuperman. 2006. “KnowledgeLink: Impact of context-sensitive information retrieval on clinicians’ information needs.” JAMIA 13(1):67-73
916 917 918 919 920 921 922 923 924 925 926 927 928 929 930 931
Still more emerging technologies, some in development and some yet to be conceived, promise to integrate advances in nanobiotechnology and genomics into patient care and the EHR-S.
After a diagnosis of serious heart problems, 67-year-old Thomas Tillman is ‘instrumented’ with a Bluetooth cardiac monitor that links to a cellular telephone network. The cell phone he carries is loaded with a network profile that notifies the network he is at risk for lethal arrhythmia. The phone’s global positioning tracking system ‘knows’ the locations of close-by hospitals and personal heart defibrillators. It also stores profiles and dynamic locations for doctors, nurses, physician assistants, and emergency medical technicians who are among its 200 million cellular users. Whether or not Tillman is awake or alert, the technology is alive and able to act as a surrogate in case of medical emergency.
932 933 934 935 936 937 938 939 940 941 942 943 944 945 946 947 948 949 950 951 952 953 954 955 956 957 958 959 960 961 962 963 964 965 966 967 968 969 970 971 972 973 974
4 Principles The Department of Veterans Affairs’ (VA’s) Computerized Patient Record System (CPRS) has been praised as one of the world’s finest systems. It is not solely the functionality it contains that led to its success. Instead, the collaborative manner in which it was developed has much to do with the system’s usefulness, integration into clinical workflow, and The new EHR-S is designed overall acceptance by VA clinicians. This historical by providers for providers. foundation provides the framework for the principles that guide VA’s new Electronic Health Record System (EHR-S). First and foremost, the new EHR-S is designed by providers for providers, with requirements, functionality, and specifications originating inside the Veterans Health Administration (VHA). Providers and their needs drive the technology. With software tools and capabilities designed to facilitate their work, providers become more accepting of the technology involved. Second, VHA providers set the direction of the new EHR-S, including feature sets and prioritization of effort. The growing medical informatics discipline makes this premise more commonplace than it once was, as evidenced by the creation of the Chief Health Information Officer and related roles throughout the health care industry. The end user has a larger role than ever before as a driver of the design. Starting with these two concepts, a series of supporting principles can be established. Most important is to create a patient-centric system. This is especially pertinent in a nationwide health care system such as VA, where Veterans often receive health care at a variety of different facilities and outside the VA system. Rather than create artificial silos of patient data that are geographically oriented, it is critical to create longitudinal records of patient health care. Recent commitments by the Secretaries of VA and Department of Defense to create a joint life-time record of federal health care and current pilot programs investigating collaboration and exchanges with outside systems point directly to the importance of this goal. Because the health care continuum ranges from hospital-based practice to ambulatory care and even home- and community-based treatment, system recognition of user context also becomes vital. The same provider may play different roles throughout each day, transitioning from a training role during business hours to situations such as a practicing Emergency Department physician in the evening. To appropriately respond to these changes, the next generation EHR-S is sensitive to the contexts of patient identity, user identity, and care setting.
975 976 977 978 979 980 981 982 983 984 985 986 987 988 989 990 991 992 993 994 995 996 997 998 999 1000 1001 1002 1003 1004 1005 1006 1007 1008 1009
Systems that are sustainable are also extensible. That is, the capacity to expand in functionality is itself a feature of the EHR. By designing a Just as the lead and framework that can manage changes in technology direction for the system and growth in the underlying clinical knowledge comes from clinicians, the databases, VA is creating a system that can remain interface is created by responsive to clinician and patient needs. applying what scientists Implementation of this principle is best achieved by have learned about how creating modular components with standard humans relate to and interfaces instead of a single monolithic program or interact with technology. one in which constituent parts cannot be easily separated and isolated. This way, any single element of the system can be replaced without as much impact on other elements, and may even lend itself to increased operation time (‘up-time’) of the EHR for clinicians. This approach also supports evolution of the system as the body of knowledge grows to support clinical decisions. The system eases knowledge discovery, fosters innovation, and facilitates changes in health care practice and information needs. For example, data visualization is readily available throughout the system; this helps providers quickly spot trends for individual patients or across a patient panel. User computing experience is an important consideration for design of the new EHR-S. Just as the lead and direction for the system comes from clinicians, the interface is created by applying what scientists have learned about how humans relate to and interact with technology. The importance and fast pace of health care mandate consideration of every keystroke, mouse click, and user action so it is easy for users to do the right thing and to recover quickly if an incorrect action is taken. Undesirable system variation is eliminated by requiring consistent approaches to common tasks. Key functions at the ‘core’ of the system are standardized while those at its periphery that address unique, local needs and practices can be custom-tailored. Enhanced communication knits together the care teams, both internal and external to VHA, as well as the patient and the patient’s family and caregivers. User education, presented in a variety of modalities and targeted to the patient’s specific needs, helps ensure adherence to treatment and medication plans.
1010 1011 1012 1013 1014 1015 1016 1017 1018 1019 1020 1021 1022 1023 1024 1025 1026 1027 1028 1029 1030 1031 1032 1033 1034 1035 1036 1037 1038 1039 1040 1041 1042 1043 1044 1045 1046 1047 1048 1049 1050 1051 1052 1053 1054
5 Direct Care Features VA’s new Electronic Health Record System (EHR-S) advances care for Veterans and improves care in various care settings including inpatient, outpatient, long-term, and mental health. By using integrated features such as clinical reminders, clinical decision support systems (CDSs), personal health records (PHRs), visual displays, and patient data warehouses, VA has emerged as an industry leader in providing high-quality, safe, and effective patient care through its EHR-S. New capabilities enable the Research shows that clinical reminders can EHR-S to combine, significantly improve care process measures. The prioritize, and determine an ability to collect sufficient timely outcome measures actual need for a clinician offers significant proof of improved outcomes at a alert, thus ending ‘alert clinically relevant level. Improved tracking and fatigue.’ display of patient- and disease-specific outcomes allow the VHA to better serve Veterans now and in the future. For example, to measure performance, VA tracks cholesterol levels in patients who have been identified with a diagnosis of ischemic heart disease (or its clinical equivalent). To help these patients reach their goal of an LDL less than 100 mg/dL, the EHR-S correlates the laboratory results for LDL with prescriptions for cholesterollowering medications, dose changes, and refill patterns. With a reminder that displays these correlations, the provider knows whether to counsel the patient about skipping refills or to increase the dose. Dr. Patel goes to enter a new blood pressure medication for a patient. As he begins to enter the order, he triggers his customized clinical support in the form of a screen displaying recent blood pressures and heart rates temporally related to (and displayed with) pertinent lab results, current blood pressure medications, and patient refill history data. Next year, when the patient tries to refill his recently expired med, he will receive a notification through his PHR portal that he is due for blood work to renew his medication, advising him to present to the lab. When the patient arrives at the lab, the test orders will be waiting, because the orders were entered automatically by system protocol.
In the new EHR-S, clinical reminders at the point of care are tailored to patient- and disease-specific data. Provider- customized screens offer displays that highlight elements critical to the provider’s practice area and the individual patient’s care. Text mining and other data mining procedures help providers design the best care management for their patients. These and other new capabilities enable the EHR-S to combine, prioritize, and determine an actual need for a clinician alert, thus ending ‘alert fatigue.’
1055 1056 1057 1058 1059 1060 1061 1062 1063 1064 1065 1066 1067 1068 1069 1070 1071 1072
An infrastructure for obtaining consistent outcome feedback from Veterans tracks quality of life measures and functional status as experienced by the patient. Integration of patient feedback with the working clinical record is feasible via the Veteran’s personal health record (PHR), using standardized and validated patient-interactive data collection instruments. The use of evidence-based algorithms to detect case management problems in inpatient, outpatient, long-term, and mental health care offers valuable benefits: fewer medical errors, better patient outcomes, decreased hospitalizations, increased adherence to guideline-based care, and more cost effective care. New technologies and new tools integrated seamlessly into the EHR-S support providers with a range of capabilities such as text mining and visual presentations of information. There are many opportunities for expansion and improvement of features to enhance direct patient care. Each of Sections 5.1 through 5.6 focuses on a particular clinical setting and discusses how the new EHR-S supports VA as it continues its efforts to provide quality care to the Veterans it serves.
1073 1074 1075 1076 1077 1078 1079 1080 1081 1082 1083 1084 1085 1086 1087 1088 1089 1090 1091 1092 1093 1094 1095 1096 1097 1098 1099 1100 1101 1102 1103 1104 1105 1106 1107 1108 1109 1110 1111 1112 1113 1114 1115 1116 1117 1118
5.1 Inpatient Care Providers The new EHR-S supports both the providers who care for Veterans in the inpatient setting and the administrators responsible for the delivery of that care. By design, it accommodates providers who have different levels of technological expertise and diverse patterns of learning and processing information. At the same time, it serves administrators responsible for monitoring quality, controlling costs, and performing other functions • Supports both providers vital to care management. and administrators • Allows easy Inpatient care providers use the new EHR-S to customization easily modify the appearance of the record and • Accepts input using customize information, highlighting or hiding items multiple modalities and to best meet their information needs. Providers devices view clinical information, unobscured by • Provides access via a administrative detail. For physicians, the single portal and presentation can be altered to display clinical interface information relevant to their specialty; the cardiologist can opt to view blood values and blood pressure readings first, while the orthopedic surgeon may focus first on x-rays. Providers enter information using multiple modalities (voice, touch, keyboard, gestures, digital pens) and a variety of devices (desktop, handheld, tablet, smart phone) from a wide range of locations, onsite and off (bedside, office, nurses station, research laboratory, home, etc.). Whether they choose Windows, Unix, Linux, or MacOS as their platform, providers are in an online environment with a smart virtual assistant to remember their preferences and use them as a base for solutions ‘on the fly.’ Devices such as beds that weigh the patient and machines that monitor vital signs gather and enter information directly and seamlessly into the EHR-S. Templates ‘learn’ the user’s habitual patterns and auto fill word or sentences, much like a cell phone does during text messaging. Information from sources external to VA can be entered directly into the EHR. New input modalities eliminate the errors introduced by transcription and by scanning that never becomes part of the computable record. In the new EHR-S, as on the Internet and in a wiki, all information is ‘tagged’ and available to the inpatient care provider at all times, using handheld wireless technology. No longer tethered to desktop computers and required to launch multiple applications, providers access inpatient records remotely via a single portal and interface for all sources and types of information, such as EKGs, radiologic images, and data from remote facilities. Information retrieval is simple and intuitive, with single sign-on and ready linkages to the medical literature, clinical guidelines, the Physician’s Desk Reference, and more.
1119 1120 1121 1122 1123 1124 1125 1126 1127 1128 1129 1130 1131 1132 1133 1134 1135 1136 1137 1138 1139 1140 1141 1142 1143 1144 1145 1146 1147 1148 1149 1150 1151 1152 1153 1154 1155 1156 1157 1158 1159 1160 1161 1162 1163 1164
The new EHR-S eases and automatically documents communication across providers, patients, and their human support systems, engaging them all in a collaborative process to manage conditions more effectively. Feedback loops across the care team make workflow smarter, by facilitating handoffs and supporting a team approach. For example, to communicate with a physician about a change in a patient’s status, a nurse uses a functionality (like video conferencing or instant messaging) that provides all the information available in the record surrounding the event (vital signs, weight, EKG, medications, etc.). When a provider discontinues a prescription written by another provider because a patient experiences an adverse drug reaction, the The new EHR-S eases and EHR-S updates the record viewed by everyone automatically documents involved in the patient’s care, in whatever facility or communication across service. To facilitate continuity and safe handoffs, providers, patients, and an on service resident signing out to an overnight their human support resident can reassign a patient list with an easily systems, engaging them all accessible, personalized ‘to do’ list and important in a collaborative process to care details to the next provider coming on duty. manage conditions more effectively. Feedback loops When a patient is being referred outside VA, the across the care team make EHR automatically forwards the Veteran’s record workflow smarter, by to ensure seamless continuity of care. Before facilitating handoffs and admission or after discharge, VA providers use the EHR-S to clarify instructions, answer questions, supporting a team schedule appointments, and automatically approach. document communication with the patient as a part of the care process. Patients preparing for elective hospitalization while still at home can easily and accurately add their outside provider prescriptions and alternative medications and herbals to their medication list and share it with their VA provider. Context sensitive clinical decision support (CDS) tools are seamlessly woven into the inpatient record. While a physician is ordering a test or writing a prescription, CDS runs in the background, reviewing the patient’s EHR to prevent duplication of care and possible drug/drug or drug/allergy interactions. For example, while a physician is writing an order for potassium replacement, the CDS performs an automatic crosscheck of potassium, magnesium, and creatinine levels. While reviewing the result of an initial chest x-ray, a physician can activate a pop up window that presents a contextual menu for ordering additional studies. The ability to act on a piece of information without leaving the section being used smoothes and speeds the physician’s workflow. New transformational features for inpatient providers include a tracking function that locates a patient in, for example, radiology or therapy when it is time for medications or a consultation. A wireless alert system reads ID badges to identify and announce any provider who enters a patient’s room. A screen on the wall displays the provider’s name and role for the patient. For the provider, the screen displays continuously updated vital signs and other important patient information. Interactive touch screen functionality
1165 1166 1167 1168 1169 1170 1171 1172 1173 1174 1175 1176 1177
grants access to the complete patient record. The same screen is used by the patient to view educational videos prescribed by the provider. Evolving functionalities further enrich the patient record. Multi-dimensional modeling incorporates patterns and abnormalities in a patient’s medical history into an avatar of a human body. Increasingly meaningful visualizations of chart information offer on demand clinical decision support as well as enhance communication and understanding across the care team—a team that includes the Veteran, the Veteran’s family if desired, and providers from all the disciplines. By design, the new EHR-S is and will remain open to modifications that incorporate new features and capabilities in response to issues yet to arise.
1178 1179 1180 1181 1182 1183 1184 1185 1186 1187 1188 1189 1190 1191 1192 1193 1194 1195 1196 1197 1198 1199 1200 1201 1202 1203 1204 1205 1206 1207 1208 1209 1210 1211 1212 1213 1214 1215 1216 1217 1218 1219 1220 1221 1222 1223
5.2 Inpatient Nursing In the inpatient setting, nursing documentation is unique. Unlike other disciplines that provide care on an episodic basis, inpatient nursing documents care at the bedside 24/7. Nursing Documentation Sophisticated security mechanisms enable nurses who are constantly in and out of multiple patients’ EHRs to use a simple one-stop platform to access/launch all aspects of patient centered care. Once there, the nurses view a panel of patients, as inpatient nursing and case management processes require. The panel can be easily customized, allowing the nurse to quickly add and/or remove patients and then to preview data displays such as pending orders for the patients within it. Nurses enter all data in computable format, using standardized terminology and a flowsheet to document observations and interventions. To ease work flow, the EHR-S allows nurses to schedule and view pending treatments, printing them when needed. More than one member of the nursing staff can make simultaneous entries into the flowsheet. While a nursing assistant documents a bed bath, To ensure continuity of for example, the registered nurse can document wound care in the same time slot. When tasks care, the EHR-S provides require multiple users to participate, for example, nurses with tools to create two nurses to verify prior to a blood transfusion, the customized notes and system allows for easy counter-signature. reports based on items entered. These facilitate The system makes certain data points in hand offs between shifts on documentation mandatory, such as providing three the inpatient floor, times a day wound care or complying with facility facilitate discharges and policy to address elopement risk during each shift. transfers, and support Once a nurse has completed a specified task for a follow up across the set number of hours, the EHR no longer asks for continuum of care. that data point when the nurse goes back into document patient care or status. To ensure no data is lost when a nurse is called away in an emergency, the system auto-saves at a set frequency. To facilitate documentation, the EHR-S allows nurses to do the following: • • • •
Compare entries (for example, lung sounds at 7 am vs. 7 pm) Create customized views to fit their practice, patients, and setting Use evidence-based logic, such as decision support tools that populate a field with questions or guidelines based on an entry or response Calculate screening tools scores, such as the Braden Pressure Ulcer Risk Screening, and interpret them to drive care decisions.
1224 1225 1226 1227 1228 1229 1230 1231 1232 1233 1234 1235 1236 1237 1238 1239 1240 1241 1242 1243 1244 1245 1246 1247 1248 1249 1250 1251 1252 1253 1254 1255 1256 1257 1258 1259 1260 1261 1262 1263 1264 1265 1266 1267 1268 1269
The documentation system supports nurses with two types of reminders. The first is a passive reminders system; this prompts the nurse when an order requires sign off or when treatments and documentation are pending. The second includes reminders that are not stored as part of the medical record. These ‘electronic The integration of sticky notes’ allow the nurse to create a ‘to-do’ item commercial clinical for a particular patient such as ‘check lab result’ information systems into with an associated date and time and priority level. the EHR-S eliminates the A registered nurse who creates a reminder can need for intensive care restrict it so it cannot be cleared by anyone else or nurses to do redundant or can opt to send it to a nursing assistant or assign it duplicate charting while it to a particular person. This ‘to-do’ list offers sort, eases access to data view, and print functions without having to go into a elements. With data patient’s EHR, and allows nursing staff to complete uploaded wirelessly and the reminder from within the flowsheet or whatever automatically from vitals documentation system is being used. machines, monitors, and Integrated and interoperable, the EHR-S allows other related equipment nurses to view medications administered in the such as IV pumps, nurses no flowsheet or in a section dedicated to the longer need to write down medication administration system. Customizable information and transfer it templates tailored to particular drugs prompt the to the EHR-S. nurse to scan in the bar-coded manufacturer and lot number when charting a vaccine, for example, and include a decision support model that seamlessly incorporates instructions such as ‘do not crush’ and high risk medication notifications into the record. When a nurse documents the effectiveness of a medication administered as needed (prn) in the flowsheet, the information is automatically transferred to the medication administration system. Once entered into one application using one modality, data crosses over to any other application. When the nurse does a fingerstick to check a patient’s blood sugar, for example, the glucometer wirelessly enters the reading into the medication administration system which in turn computes the appropriate dose of insulin ordered by sliding scale for that patient. The integration of commercial clinical information systems into the EHR-S eliminates the need for intensive care nurses to do redundant or duplicate charting while it eases access to data elements. With data uploaded wirelessly and automatically from vitals machines, monitors, and other related equipment such as IV pumps, nurses no longer need to write down information and transfer it to the EHR-S. This eliminates transcription errors, improving patient safety, and allows nurses to spend more time in direct patient care, interacting with and educating their patients
1270 1271 1272 1273 1274 1275 1276 1277 1278 1279 1280 1281 1282 1283 1284 1285 1286 1287 1288 1289 1290 1291 1292 1293 1294 1295 1296 1297 1298 1299 1300
Communication The EHR-S provides a range of communication capabilities that empower inpatient nurses to fulfill their roles as health care team members committed to providing Veterans with efficient, effective care. To ease communication between nurses and providers, the EHR-S allows the nurse to click on an order that is unclear and to send a page directly from that point asking for clarification. To facilitate care planning, the EHRS provides decision support based on protocol and items entered. Nurses use this system to build an evidence-based plan of care, to update an existing plan, and to issue timed triggers for re-evaluation of active problems. To support the role of the patient on the care team, the system gives nurses easy access to patient education materials. To ensure continuity of care, the EHR-S provides nurses with tools to create customized notes and reports based on items entered. These facilitate hand offs between shifts on the inpatient floor, facilitate discharges and transfers, and support follow up across the continuum of care. This support includes a unique database within the EHR-S for retrieving and updating at future admissions, easing the admitting process for patients and nurses alike.
The EHR-S provides a range of communication capabilities that empower inpatient nurses to fulfill their roles as health care team members committed to providing Veterans with efficient, effective care.
To support the management roles inpatient nurses play in a dynamic environment, the EHR-S allows them to create reports for administrative purposes that can be easily customized and exported to other users. This includes the ability to query across a group of patients and any unique data elements as well as a strong search capability that can look for items in notes and perform key word searches across any part of the chart.
1301 1302 1303 1304 1305 1306 1307 1308 1309 1310 1311 1312 1313 1314 1315 1316 1317 1318 1319 1320 1321 1322 1323 1324 1325 1326 1327 1328 1329 1330 1331 1332 1333 1334 1335 1336 1337 1338 1339 1340 1341 1342 1343 1344 1345
5.3 Outpatient Care Outpatient medicine is a complex area to manage: it requires continual evaluation and reassessment of old and new data; making and reviewing decisions over a continuum of a patient’s entire health care history rather than during a finite inpatient stay. It is delivered in varied settings, from medical centers, to the home, to community based clinics and more by multiple professionals, including nurses, physicians, pharmacists, and other health care providers.
Designed as a multiprofessional health record, the EHR-S facilitates smart workflow by offering different customizable screen views prompted by the professional and personal profile of the provider who is accessing the chart.
The new EHR-S speeds workflow by providing a rapid universal login. Designed as a multiprofessional health record, it facilitates smart workflow by offering different customizable screen views prompted by the professional and personal profile of the provider who is accessing the chart. It supports varied learning models and preferences, and provides graphics such as anatomical views that can be modified to document patient information and physical exam findings. It is compatible with different methods of data entry into the record, allowing handwriting or voice recognition as well as keyboarding or mouse clicks. To ease patient flow, the new EHR-S provides a single record for each unique Veteran across the entire continuum of VA care. This supports the continuity of care and helps control costs by eliminating duplication of care and potential iatrogenic events. If, for example, a patient experiences a drug/drug interaction necessitating discontinuation of a medication provided at another facility, the system-wide record facilitates this process. To create a comprehensive record for each patient, the EHR-S allows for the secure transmission of selected portions of up-to-date patient information outside VA when patients require transfers, placements, home health services, outside provider consultations, or community emergency care. It then integrates data returned from those encounters outside VA back into the patient’s longitudinal record. When Dr. Feng begins his day at the Primary Care Clinic, he uses fingerprint-enabled single sign-on to access his personalized portal to the EHR-S, tailored to fit his practice needs and preferences. Along with his schedule for the day, the screen shows which patients have checked in at the kiosk and seen the nurse. It even shows him where in the clinic he can find his nurse, who wears a standard VA geotagged ID badge. When he accesses his first patient’s EHR, he sees the information gathered at the kiosk and by the nurse, along with the newest laboratory values for the data fields he has selected for display. Seeing an elevated blood pressure reading, he clicks to check the patient’s family history for hypertension from previous exams. Seeing a recent pattern of elevated levels, Dr. Feng discusses diet and lifestyle changes with the patient, refers him to the nutritionist, and closes the patient’s EHR.
1346 1347 1348 1349 1350 1351 1352 1353 1354 1355 1356 1357 1358 1359 1360 1361 1362 1363 1364 1365 1366 1367 1368 1369 1370 1371 1372 1373 1374 1375 1376 1377 1378 1379 1380 1381 1382 1383 1384 1385 1386 1387 1388 1389 1390 1391
The EHR-S supports Veterans in their roles as members of the VA health care team. Secure patient portals accessible on home computers, • Securely transmits data mobile devices, and VA kiosks allow patients to outside VA when a confirm contact, insurance, and medication Veteran requires noninformation (medication name, dose, and specific VA services manufacturer). To accurately reconcile their actual • Integrates data from dosing regimen for comparison with their outside encounters back prescribed regimen, the system shows patients a into the Veteran’s EHR list of their prescribed medications and links to a picture of the pills via an online medication patient education link in real-time. By requesting the patient then verify their regimen or annotate it with their actual use, any discrepancies are identified. The system also asks patients to enter in over-the-counter medications and any alternative or herbal preparations they are taking. This provides for truly integrated management of the patient’s medication information, helping to circumvent potential safety issues with patient dosing errors or interactions. Proactive reminders alert patients to studies, screenings, and preventive measures that are essential to recognized standards of care. Secure patient portals allow providers to concentrate more efficiently on the visit. Providers and staff contact their patients using direct messages on the portal, and patients use features • Collects crucial data on the portal to complete necessary pre-visit prior to appointments items. In addition to confirming medications, for • Maximizes time example, a Veteran can arrange to complete available to conduct a required studies or labs, obtain outside records, thorough physical exam, take preventive measures, or enter home health discuss issues face to readings such as blood pressure or glucose face, and make values. Providers use the portals to send ‘information prescriptions’ to patients, with links to collaborative treatment VA vetted information on health conditions and decisions responses to frequent patient queries about health issues and lab results. These portals, along with additional electronic means, can also help contact a patient for an alert if a provider is unexpectedly unavailable for a scheduled visit. With crucial data collected prior to appointments, outpatient visits are maximized for Veterans receiving care as well as for provider productivity. There is time to conduct a thorough physical exam, discuss issues that need true face to face interaction, and make collaborative treatment decisions. For example, when labs are completed prior to a visit, the patient and provider can discuss in person the need to adjust medication dosages, instead of the need for post visit labs that would then require additional follow up. Having complete data during the visit also allows the provider to use ‘on demand’ clinical decision making tools while the patient is present, enhancing clinical workflow and best practices. Having more time to talk with patients during a visit facilitates
1392 1393 1394 1395 1396 1397 1398 1399 1400 1401 1402 1403 1404 1405 1406 1407 1408 1409 1410 1411 1412 1413 1414 1415 1416 1417 1418 1419 1420 1421 1422 1423 1424 1425 1426 1427 1428
provider communication, 26 and studies of medication adherence in hypertensive patients 27 and self-management in diabetic patients28,29 show that the quality of patientprovider communication improves health outcomes. Outpatient providers use advanced methods to interact with patients, optimizing productivity and communication. Sophisticated visualization tools allow providers to incorporate data from an individual patient’s record and display it in ways that facilitate the recognition of patterns and abnormalities. Providers use three-dimensional images and models for decision support and patient Sophisticated visualization communication. Eventually models will incorporate tools allow providers to a patient’s medical history into an avatar of a incorporate data from an human body. individual patient’s record and display it in ways that Other new features improve workflow facilitate the recognition of management, including tasks and data not patterns and abnormalities. necessarily reflected in the patient’s direct care Providers use threerecord. Improved communication among team dimensional images and members and patients ensures necessary tasks models for decision support are completed in a timely and appropriate manner. and patient A flexible scheduling package integrates the full communication. range of outpatient appointments, from primary care to radiologic studies, labs, consults, therapies, social services, etc. Improved communication and coordination expand the roles of clerical and clinical staff and facilitate true case management. The patient has direct contact with the team, not just the primary provider, easing workflow and ensuring that the patient’s needs are promptly and appropriately triaged. To optimize clinical effectiveness, the new EHR-S communicates data to, and requires input from, the provider identified as having the knowledge and training to best interpret the studies recommended or ordered. This results in the best possible care plan and supports a true team approach to health care, one that affords a ‘medical home’ for every Veteran who receives care from the VHA. On what is a fully integrated health management platform, every patient becomes a ‘node,’ or point, on an all encompassing health network.
26
J Solomon. 2008. “How strategies for patient visit time affect physician job satisfaction: a qualitative analysis.” J Gen Intern Med 23(6):775-780. DOI: 10.1007/s11606-008-0596-y 27 A Schoenthaler, WF Chaplin, JP Allegrante, et al. 2009. “Provider communication effects medication adherence in hyptertensive African Americans.” Patient Educ Couns 75(2):185-191. DOI: 10.1016/j.pec.2008.09.018. 28 M Heisler, RR Bouknight, RA Hayward, et al. 2002. “The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management.” J Gen Intern Med 17(4):243-252. 29 R Bundesmann, SA Kaplowitz. 2010. “Provider communication and patient participation in diabetes self-care.” Patient Educ Couns . 2010 Oct 27 [Epub ahead of print].
1429 1430 1431 1432 1433 1434 1435 1436 1437
By design, the new EHR-S facilitates workflow, never drives or encumbers it. New technologies, such as smart phones and other portable wireless devices give providers flexibility and the ability to access to patient records and place orders immediately and securely, wherever they may be. An outpatient provider at a community clinic, for example, can quickly access a patient’s complete record to determine how to interpret a page from the lab with an elevated white blood count. By supporting provider flexibility and movement, the new EHR-S empowers them to deliver timely and appropriate care anywhere.
1438 1439 1440 1441 1442 1443 1444 1445 1446 1447 1448 1449 1450 1451 1452 1453 1454 1455 1456 1457 1458 1459 1460 1461 1462 1463 1464 1465 1466 1467 1468 1469 1470 1471 1472 1473 1474 1475 1476 1477 1478 1479 1480 1481 1482 1483
5.4 Long Term Care The new EHR-S follows Veterans as they need care provided in a range of inpatient, outpatient, home, and community based long term care settings. In 2009, 59% of the VA’s extended care population received care from non-institutional services, including geriatric evaluation, geriatric primary care, home-based primary care, purchased skilled home care, adult day health care, homemaker and home health aide services, home respite care, home hospice care, and community residential care. • Access to products developed specifically The EHR-S also follows those Veterans, no matter for long term care what their age, who need nursing home care and • Tools to assess case mix whose service-connected disability ratings qualify and gather data needed them for institutional long term care provided by VA to manage care Community Living Centers located within or near • Clear and VA medical centers, nursing homes within local comprehensive patient communities, or State Veteran Homes. On any profiles that also reveal given day in 2010, more than 35,000 Veterans trends received this level of care. In settings that provide extended care, the nurse case manager is responsible for creating intersections in health care delivery between the patient, family, and all aspects of the interdisciplinary care model. The new EHR-S eases the case manager’s tasks, by providing access to products developed specifically for long term care, not adapted from acute or outpatient care settings. These and other capabilities of the EHR-S support clear and concise communications among all types and levels of providers involved in extended care. To integrate patient care planning with patient care delivery, the EHR-S accommodates tools to assess case mix and gather the data needed to manage utilization, cost, and quality outcomes for Veterans grouped at levels of acuity ranging from highest need for services to lowest. These capabilities support VA in providing appropriate care with an effective use of resources. As health information follows Veterans from setting to setting, improved communication helps Veterans, caregivers, family members, and care providers transition between them. The comprehensive data collected by and accessible through the EHR-S provides a clear patient profile that includes diagnosis, interdisciplinary care planning, treatment, documentation, and outcomes. This has the added benefit of identifying trends that can be used to monitor and improve outcomes for groups of patients. By coordinating care across multiple settings, the EHR-S reduces wait times and treatment delays, improving patient satisfaction and, potentially, outcomes as well. As the repository of complete patient information, the integrated EHR-S becomes a ‘team
1484 1485 1486
member’ by supporting treatment protocols as Veterans move through the health care system.
1487 1488 1489 1490 1491 1492 1493 1494 1495 1496 1497 1498 1499 1500 1501 1502 1503 1504 1505 1506 1507 1508 1509 1510 1511 1512 1513 1514 1515 1516 1517 1518 1519 1520 1521 1522 1523 1524 1525 1526 1527 1528 1529 1530 1531 1532
5.5 Mental Health Mental disorders typically treated in VA can be chronic and disabling and may become acutely life-threatening at any point in the Veteran’s lifespan. Disturbed behavior due to a mental disorder can pose a risk to the Veteran or others, including caregivers. Understanding the biological basis of mental illness is an emerging field. What we ‘know’ today is likely to be replaced with new knowledge tomorrow. Effective treatment of mental illness may require specialized knowledge that spans the domains of neuroscience, general Useful tools include medicine, psychology, and sociology. Further displays that permit the complicating the complexity of mental disorders is correlation and the frequency of co-morbidities, such as physical visualization of therapeutic disorders, addictions, and other mental disorders. drug trials, together with observed and self-reported Mental illness is socially stigmatized. The Veteran symptom status and new with mental illness may lack a strong social patient-interactive history network, yet successful intervention may require taking tools. calling upon that network at any time. Mental illness may go into remission only to surface years later. Long intervals of apparent good health may be punctuated by severe exacerbations requiring complex treatment plans. The course of mental illness is often prolonged and patients may move many times during the course of illness. Crucial knowledge gained in one location has the potential to be lost in a move. The ‘core data’ of a mental disorder is the patient’s evolving personal narrative. Milestone events, such as knowledge of a trauma, are key to understanding the patient. Time spent searching the record to recover a ‘story’ can orient the caregiver and inform an intervention. The more quickly and completely the story and its treatment history can be pieced together, the more likely an appropriate intervention can be made. The new EHR-S plays an important role in assisting care of mentally ill Veterans. As discussed above, tools to assemble and store a current narrative history of the patient’s illness can contribute to timely and targeted treatment plans. System features track and correlate the patient’s outcome with therapeutic trials and document the severity of the patient’s illness. Other useful tools include displays that permit the correlation and visualization of therapeutic drug trials, together with observed and self-reported symptom status and new patient-interactive history taking tools. Interdisciplinary input can prove invaluable in detecting changes in status. Patient-reported information in Veterans’ personal health records (PHRs) is accessible to the decision maker using the health record. Mental health system care managers use tools to track the transition of vulnerable populations across time and space, profile their functional status, and monitor for any cases that are lost to follow up. Individual practitioners utilize global views to track
1533 1534 1535 1536 1537 1538 1539 1540 1541 1542 1543 1544 1545 1546 1547 1548 1549 1550 1551
outcomes and visualize the clinical status of Veterans in their practices. Alerting tools warn caregivers about behavior risk conditions. Sophisticated alert management tools assure that notifications and warnings are current, valid, and issued to the correct recipients; that they respect the privacy of the Veteran and result in no stigma; and that alerts no longer applicable are retired promptly per uniform procedures. Meeting the unique needs of Veterans and their mental health providers demands secure and accountable communication channels with fail-safe features that extend across different modalities. Communications are vital to the alliance between Veterans, providers, and care teams. Veterans who call the VA’s nationwide 24 hour suicide hotline, for example, need access to local facilities and mental health professionals; facilities and professionals in turn need access to the Veterans’ EHRs. . In crisis situations, tools on the clinical desktop indicate when a conservatorship is in place and whether dates authorizing information release are current, so providers answering a telephone can immediately determine who may receive information and, ultimately, who may assist a patient in need. They also enable remote consent for disclosure.
1552 1553 1554 1555 1556 1557
5.6 Clinical Decision Support
AWAITING CONTRIBUTION
1558 1559 1560 1561 1562 1563 1564 1565 1566 1567 1568 1569 1570 1571 1572 1573 1574 1575 1576 1577 1578 1579 1580 1581 1582 1583 1584 1585 1586 1587 1588 1589 1590 1591 1592 1593 1594 1595 1596 1597 1598 1599 1600 1601 1602 1603
5.7 Operations Management and Communications Safe, effective patient care depends on providers having access to information at point of care and communicating accurately with clinical staff and patients. The new EHR-S integrates data from clinical modules such as laboratory, radiology, and pharmacy. It exceeds the capabilities of earlier systems, offering enhanced views of patient information and extending automated data capture from facilities elsewhere in VA and, as part of the Virtual Lifetime Electronic Record (VLER), from the Department of Defense (DoD). Tools provided by the EHR-S and available by smartphone, To facilitate operations, it provides for appropriate workstation, or handheld billing based on patient visits and new modalities devices support coordination for communication, including smartphone and and communication with all telehealth applications. In addition, the EHR-S members of the care team, offers advanced integrated scheduling. As a including the patient and result, referrals to specialists are timed to occur family (if desired), providing after required pre-visit studies being booked at for seamless hand-offs and the same time have been completed, ensuring ensuring follow-up. that specialist has the data needed for the visit. To be comprehensive, the new EHR-S also integrates data from private sector clinicians and from the Veterans’ own personal health records (PHRs). Designed for interoperability and supported by VA collaborations with DoD and the private sector, the new EHR-S captures this information in computable, machine-readable formats. Readily indexed for retrieval and easily browsed for critical elements, the data captured is available for reuse when appropriate, while redundancies are eliminated. When 34-year-old Derek Jones presents to a VA facility requesting controlled substance pain medication, the provider calls up Jones’ EHR. Linked by the Nationwide Health Information Network with national and state records, the EHR-S reveals that Jones has recently begun filling multiple prescriptions for controlled substances from several private providers. Upon discovering this, the VA provider intervenes and discusses the problem with Jones, who realizes he needs help with his addiction. Before the appointment is over, the provider refers Jones to VA counselors for treatment.
The EHR-S offers clinical staff easy access to authoritative, knowledge-based reference tools to aid clinical decision making. Judiciously issued clinical alerts and reminders prompt staff to respond to clinically significant situations. (Too many, and their benefits diminish, as providers experience ‘alert fatigue.’) These features have enabled the VA to outperform private sector health care organizations on clinical performance measures relevant to the management of chronic disease and the delivery of preventive care. For the communication of clinical data, the EHR-S follows electronic data interchange (EDI) standards (health care entity to entity) and health care message format standards
1604 1605 1606 1607 1608 1609 1610 1611 1612 1613 1614 1615 1616 1617 1618 1619 1620 1621 1622 1623 1624 1625 1626 1627 1628 1629 1630 1631 1632 1633 1634 1635 1636 1637 1638 1639 1640 1641 1642 1643 1644
(between computer systems within a health care entity or facility). These standards allow for the transformation of clinical data into relevant and useful information for health care professionals in varied roles as well as Veterans. Accounting for the individual’s role, the EHR-S provides contextually sensitive, evidence-based decision-making tools. In addition, it discerns and displays meaningful patterns in the data, presenting them visually or issuing alerts when appropriate. The communications capabilities built into the EHR-S enable care providers to manage not only individual patients, but also groups of patients and clinician workflows. Providers can follow a Veteran seeing multiple clinicians throughout the diagnostic and treatment process. Tools provided by the EHR-S and available by smartphone, workstation, or handheld devices support coordination and communication with all members of the care team, including the patient and family (if desired), providing for seamless hand-offs and ensuring follow-up. Other tools, now emerging, promise to further improve health care quality by identifying trends, such as prevalence of antibiotic resistant organisms and flu strains, on an ongoing basis. To foster efficiency, the new EHR is designed to be intuitive and accessible anytime and anywhere so Veterans and care providers can share health information, consult, and communicate outside of a traditional hospital setting or during a weekday clinic visit. Increasingly mobile, Veterans and clinical staff have many new choices for health care delivery in non-institutional settings, particularly when geographically separated. While visiting family in Albany, New York, 57-year-old James Mohammed is hospitalized at the local VA for a serious adverse reaction to a medication prescribed by his primary care provider at the Salt Lake City VA. The inpatient pharmacist enters an Adverse Drug Reaction, visible to the entire VA system, and the care team cancels the open prescription in Salt Lake City to ensure that the medication is not accidentally refilled or re-prescribed when Mohammed returns home. After discharge, when Mohammed decides to stay in Albany a little longer, he realizes he is running low on his other usual prescription medications. The pharmacist in Albany enters a temporary address that triggers an open refill from the Salt Lake City VA to ensure that the medications arrive in Albany.
In short, the new EHR-S facilitates care delivery, collaboration, and communication between patients, their families, VA and non-VA clinical care providers, regardless of geographic location, time of day, and the user's preference for mode of communication. Lessons learned from Hurricane Katrina and other disasters underscore the necessity of planning for systems that allow for seamless and interactive care delivery in the event of local or regional computer outages.
1645 1646 1647 1648 1649 1650 1651 1652 1653 1654 1655 1656 1657 1658 1659 1660 1661 1662 1663 1664 1665 1666 1667 1668 1669 1670 1671 1672 1673 1674 1675 1676 1677 1678 1679 1680 1681 1682 1683 1684 1685 1686 1687 1688
6 Self Care Features As the Institute of Medicine concludes in Crossing the Quality Chasm (2001), providing health care that is safe, effective, patient-centered, timely, efficient, and equitable requires new approaches to health care design. In the area of self care, these include fostering continuous healing relationships between Veterans and providers, and providing tools that help Veterans become more active participants in their health.
Engaging Veterans in self care is a holistic approach that has the potential to empower Veterans, improve quality of life, increase satisfaction, reduce the risk of adverse events, decrease cost, and lessen pain.
Information technology enables patient-centered care by offering new ways to support health maintenance and wellness activities, customized to Veterans’ individual needs and values. New tools support active partnerships and knowledge sharing between Veterans and their health care teams. The VA’s web-enabled personal health record (PHR) exemplifies these new approaches. It both enhances the delivery of services to Veterans and promotes the active engagement of Veterans in their own care. As a complement to VA’s electronic health record (EHR), the PHR empowers Veterans with the information, tools, and resources needed to stay healthy, make informed health care decisions, and access needed services. A powerful collection of tools that promote self care, the PHR enables the development of a more comprehensive longitudinal record of care, improving the coordination of care across multiple providers, and easing transitions from one setting to another. Together the PHR and EHR enhance Veteran-provider communication, enable data and information sharing, and support Veteran engagement. Self care or self management is a key concept in health promotion. It embodies the decisions and actions taken by individuals to improve their health or cope with a health problem or condition. Self care activities and behaviors range from information seeking and decision-making to behavior and lifestyle changes, with the goal of enhancing health, preventing disease, limiting illness, or restoring health. As a complement to professional health care, self care is especially important for Veterans with chronic illnesses. Worried when her blood glucoses run high despite her attempts to eat ‘no sugar’ and ‘low sugar’ foods, Mrs. Tesfasilase, a newly diagnosed diabetic, contacts her health care team nurse. An assessment reveals she is having difficulty identifying a proper diabetic diet and is not accounting for other sources of carbohydrates besides ‘sugar’ in her diet. With an electronic ‘knowledge prescription’ sent by the nurse, Mrs. Tesfasilase uses her PHR to access a patient-friendly course on carbohydrate counting and food choices appropriate for a diabetic. Her blood glucoses respond appropriately to her newfound knowledge.
1689 1690 1691 1692 1693 1694 1695 1696 1697 1698 1699 1700
Engaging Veterans in self care is a holistic approach that has the potential to empower Veterans, improve quality of life, increase satisfaction, reduce the risk of adverse events, decrease cost, and lessen pain. Veteran concordance with medical advisement and treatment may also be an important factor in improving health outcomes. As part of a personal health maintenance model, self care can be directly supported using information technology tools that enable access to high quality information to support self management, provide decision support tools, offer accessible and convenient options for interactions with the health care system, and create a comprehensive longitudinal EHR that also includes Veteran-supplied information.
1701 1702 1703 1704 1705 1706 1707 1708 1709 1710 1711 1712 1713 1714 1715 1716 1717 1718 1719 1720 1721 1722 1723 1724 1725 1726 1727 1728 1729 1730 1731 1732 1733 1734 1735 1736 1737 1738 1739 1740 1741 1742 1743 1744 1745 1746
6.1 Access to Personal Health Records VA’s PHR is a robust set of tools that enables secure access to health data, Veteran controlled data sharing, decision support, convenient electronic transactions and services, and easy access to educational tools and resources based on the individual Veteran’s needs and preferences. The PHR supports self care by offering rich features to Veterans and allowing Veterans to control what information and data they send to, and receive from, their providers. The features provided by the PHR are consistent with features of the EHR-S and • Allows control over the include the following: information and data Veterans send to and Privacy and Security: The PHR includes a strong receive from their technical architecture that is supported by providers standardized organizational processes to ensure • Supports industry-wide that Veteran privacy is reliably protected, security standards for is maintained, and users have a clear information exchange understanding of the terms and conditions of use. • Allows Veterans to receive reminders via Veteran Control: Veterans control their own PHR, the delivery method personalizing which information appears on their PHR ‘home page.’ Veterans also control access. they choose For example, they can authorize access by selecting a health care proxy; they can identify what data can be shared and over what timeframe. If they wish, they can view the audit log that maintains detailed records of access history. They can even select a ‘break the glass’ option for data availability in event of acute illness or emergency. Interoperability and Data Liquidity: Like the EHR-S, the PHR fully supports industrywide standards that enable health information exchange, data liquidity, and portability among multiple systems. Veterans can import data from other systems into the PHR, including data related to care received from non-VA health care providers and systems. They can export data from the PHR to other platforms and tools, support population health, or enable informed participation in approved research studies. Veteran Access to Electronic Health Record Data: The PHR contains copies of data extracted from the EHR-S to enable Veteran access to all relevant health data, including administrative data like appointments, clinical data like laboratory test results and pharmacy data, and medical information like problem lists, discharge summaries, and treatment options and goals. Veterans receive reminders for events such as appointments and prescription refills and can specify the manner of delivery, for example, a text message or calendar alert. An after-visit summary is sent to the Veteran’s PHR. This includes a Veteran-friendly description of the encounter, identifies specific goals and actions associated with the visit, and includes the ‘information prescriptions’ the provider deems necessary for effective self care.
1747 1748 1749 1750 1751 1752 1753 1754 1755 1756 1757 1758 1759 1760 1761 1762 1763 1764 1765 1766 1767 1768 1769 1770 1771 1772 1773 1774 1775 1776 1777 1778 1779 1780 1781 1782 1783 1784 1785 1786 1787 1788 1789
Veteran Supplied Data: Veterans can document, maintain, and store data and information in the PHR to construct a comprehensive record that includes family, medical, and military history; medications, non-VA prescriptions, herbals, and supplements; allergies; immunizations; vitals and health readings; food and activity journals, and health goals and action plans. The PHR enables direct entry of data from medical devices, tools, and applications, and also includes relevant metadata, such as source attribution for all data in the record, so the Veteran or the provider viewing data can always confirm its original source. • Sends after-visit Provider Access to Veteran Supplied Data: The PHR includes data and information the Veteran has authorized for sharing and is annotated with source attribution. The value of such data is enhanced by the ease with which the provider can access and make meaningful use of information supplied by the Veteran’s personal history, medication lists, health goals, and data entered directly from home monitoring devices such as glucometers.
•
•
summaries to the Veteran’s PHR, including ‘information prescriptions’ Enables direct entry of data from medical devices and applications, with identifying metadata Personalizes information for the individual Veteran
Health Education Information, Tools, and Resources: The PHR enables access to rich health education information, tools, and resources in a variety of media formats that facilitate knowledge and understanding to promote self care and informed decision-making. Information is personalized for the individual Veteran and customized to accommodate cultural characteristics and values as well as languages, literacy skills, and learning preferences by providing a range of audiovisual and print-based materials. The PHR can also include information on alternative therapies and strategies not provided by VA. Decision Support Tools: The PHR provides Veterans with easy access to robust decision support tools that include wellness reminders for preventive care, drug interaction tools, data-driven assessments and recommendations based on evidencebased guidelines and alerts and reminders that support self care activities and behaviors. Social Media, Group Participation, Peer Support: The PHR supports interactive communities that leverage social media tools and techniques to enable new methods of communication and peer support.
1790 1791 1792 1793 1794 1795 1796 1797 1798 1799 1800 1801 1802 1803 1804 1805 1806 1807 1808 1809 1810 1811 1812 1813 1814 1815 1816 1817 1818
6.2 Access to Health Knowledge The provision of health care is an informationintensive activity, and effective self care depends on easy access to accurate and relevant resources presented in a format that Veterans can understand and apply. Accessible anywhere a cell phone or laptop can be used, the PHR facilitates access to educational resources in user-friendly and engaging ways that address the Veteran’s level of health literacy and preferences.
Personalized links to relevant information resources serve as ‘information prescriptions’ to promote health knowledge and actionable self care.
Well organized and searchable content libraries supplemented with context-specific links support effective information seeking, retrieval, and use. Personalized links to relevant information resources serve as ‘information prescriptions’ to promote health knowledge and actionable self care. Tools in the PHR assist in knowledge acquisition, guide decision-making, and foster Veteran engagement. For example, navigation tools help Veterans create customized knowledge bases for later reference. Screening and risk assessment tools support health-related decision-making, while multiple formats and multiple communication channels allow Veterans to access information using a variety of devices. Interactive simulations model the effects of changes in activity and behavior on health status to motivate Veterans. Chronic disease management tools include information on sleep, diet, exercise, actual medication intake, etc., as the base for actionable recommendations for healthy living and disease management.
1819 1820 1821 1822 1823 1824 1825 1826 1827 1828 1829 1830 1831 1832 1833 1834 1835 1836 1837 1838 1839 1840 1841 1842 1843 1844 1845 1846 1847 1848 1849 1850 1851 1852 1853 1854 1855 1856 1857 1858 1859
6.3 Schedule Management and Communication The PHR component of the EHR provides Veterans with integrated tools that ease their task of managing day-to-day details of self care and enhance their role on their individual health care team. Schedule Management. Tools support dynamic appointment requests and scheduling to accommodate Veterans’ needs and preferences, thus enhancing access. Advance check-in tools enable Veterans to complete traditional ‘clipboard tasks,’ including the review and update of administrative and clinical data and medical history changes. Veterans are provided with previsit educational resources and encouraged to document questions and concerns in a pre-visit journal that can be shared with the health care provider. Appointment events and tasks populate the Veteran’s PHR calendar; alerts and reminder tools provide additional options.
•
•
For the health care team, secure messaging is integrated into the clinical workflow through the EHR-S. For Veterans, secure messaging means robust, easy-to-use features.
Communication. Emerging technologies have made new methods of communication available to supplement traditional health care interactions. At times, these appropriately replace face-to-face interactions, such as an administrative inquiry, a request for clarification or test results, or a follow up in between office visits. Secure messaging, available through the PHR, allows Veterans to interact with their VA health care team to exchange non-urgent health-related information, attend to administrative needs, and, when appropriate, connect in lieu of an office visit or telephone call. For Veterans, secure messaging enhances communication and improves satisfaction, efficiency, and care management through the PHR. For the health care team, secure messaging is integrated into the clinical workflow through the EHR-S. The EHR-S supports Veteran-initiated secure messaging, provider initiated communication with individual Veterans or Veteran groups, and Veteranprovider ‘e-visits.’ Tools integrated into the EHR facilitate electronic communication, enable documentation, and track workload. Additional tools support secure access through mobile devices. For Veterans, secure messaging means robust, easy-to-use features for sending, receiving, displaying, tracking, and storing messages, with context sensitive user help.
1860 1861 1862 1863 1864 1865 1866 1867 1868 1869 1870 1871 1872 1873 1874 1875 1876 1877 1878 1879 1880 1881 1882 1883 1884 1885 1886 1887 1888 1889 1890 1891 1892 1893 1894 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905
7 Population Health Population health is health care targeted at groups of patients, rather than focused on the care of a single patient, and is made possible by a well-designed, integrated EHR. Population health focuses on the identification and impact of health conditions and risk factors at the population level and will greatly improve the ability of the Veterans Health Administration (VHA) to accurately predict health care needs, target preventive care for those most at risk, and identify areas where public health The EHR-S supports the strategies are needed. population health approach Population health data has many uses for VHA. by consistently collecting Because of the ability to determine the incidence data on diseases, disease and prevalence of health conditions, population burden, and risk factors in a health data allows VHA to more accurately predict standardized manner that current and future health care needs, thus allows automatic improving long-term planning for clinical care. calculation of population Population health data allows for the targeted health data. development of public health programs focused on medical conditions and risk factors that are prevalent and likely to lead to adverse health outcomes. This directs resources to programs and enables personal messages for individuals at risk, thereby allowing patients to understand their risk factors, potential morbidity, and what they can do to increase their odds of a good outcome. The EHR-S supports this population health approach by consistently collecting data on diseases, disease burden, and risk factors in a standardized manner that allows automatic calculation of population health data. Identification of diseases involves identification of relevant diagnostic codes, linkage with laboratory and pathology data, immunization records, and procedures including screening and diagnostic tests. The identification of risk factors includes demographic data (e.g., age, race, sex), biological data (e.g., labs, vital signs), behavioral data (e.g., smoking, alcohol consumption), and exposure history (e.g., in military and occupational situations). The new EHR-S accurately captures the full medical history using a structured approach or free-text processing to make all the data in the electronic record sharable. Internal registries facilitate the program evaluation necessary to continue to improve clinical care. For instance, as patients have joint replacements, they are automatically added to a registry of such patients, so outcomes are automatically documented and calculated, providing temporal trends as the organization and practice of medicine evolve. The EHR-S allows the rapid (or automatic) assembly of clinical and historical data across patient populations, resulting in population data that can be used to perform long-range planning as well as address the immediate clinical needs of Veterans.
1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938
7.1 Disease Surveillance Collected on an ongoing basis and appropriately de-identified to protect patient privacy, population health data will provide the basis for disease surveillance. The most immediate benefits will come from tracking infectious diseases, such as influenza like illness, using data from the new EHR-S and thus specific to the age, gender, comorbidities, etc. of the Veteran population. System-wide data from ongoing real-time disease monitoring will allow VHA to use disease modeling tools that can better predict disease outbreaks among Veterans and, in turn, better target interventions, such as intensified prevention and vaccination programs. Over the longer term, disease surveillance will allow VHA to identify health problems as they are emerging. Inclusion of data on military and occupational exposure history, for example, will help clarify problems such as Agent Orange in the Vietnam Era and the emergence of the Gulf War Syndrome during the first Gulf War. Data entered by Veterans themselves into their own personal health records for uploading into the EHRS will make new levels of details available for analysis. Over time, surveillance promises to increase the understanding of chronic diseases as well. Researchers can search for patterns in the medical data and explore possible relationships between diseases and patterns in behavioral and/or exposure data. Long-term data-driven studies, such as the Framingham (MA) study of heart disease, have changed public health, clinical medicine, and personal behaviors in the past. The growing wealth of computable and shareable data from the EHR-S, linked with public and private sector data, will support data-driven exploration without requiring expensive investment into specific study sites or retrospective data collection.
System-wide data from ongoing real-time disease monitoring will allow VHA to use disease modeling tools that can better predict disease outbreaks among Veterans and, in turn, better target interventions, such as intensified prevention and vaccination programs.
1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969
7.2 Disaster Preparedness Features of the next generation EHR-S include items to facilitate providing care to Veterans impacted by a disaster. Alternate contact information for a local friend, relative, or significant other helps contact the Veteran during or after a disaster. The incorporation of standardized tools such as ‘The Impact of Event Scale’ used in assessing Post Traumatic Stress Disorder (PTSD) allow for rapid, and standardized, evaluating of displaced Veterans allowing VHA to better address their short- and longterm needs after an event. Disaster and emergency preparedness plans account for the types of hazards likely in a geographic area (e.g., earthquake, flood, hurricane, or tornado) and for the types of patients most likely to be impacted. For example, there are back up plans for patients on dialysis, home oxygen therapy, etc. For patients with chronic medical conditions, plans include the need to have medical supplies and medications available in case of evacuation or the need to ‘shelter-in-place.’ These facility-focused plans are complemented by the capabilities of the EHR-S. Available across and throughout the entire system, it provides for seamless care of evacuated or displaced patients. Vital health information is protected from loss even when individual facilities are rendered inoperable. Additionally, in the event of a nonfunctional or inaccessible EHR, providers have ‘view’ access to data in the health record so patient care can continue uninterrupted. Health records for Veterans remain available in the EHR-S and accessible using a variety of devices including smartphones. In the event that Veterans must turn to the private sector during a disaster, their records remain accessible. To further protect Veterans in disasters, the EHR-S is designed for interoperability with patient movement and tracking systems being developed for use by other agencies within the Federal government.
1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
8 Supportive Functions Supportive functions in the EHR-S address the range of administrative and financial requirements that facilitate patient care. As defined by Health Level 7 (HL7), these include support for medical research, public health, and quality improvement. VA’s EHR-S provides this array of functions by enabling standards-based interactions among systems (internal and external) and by making standards-based data available for multiple uses and multiple users that support health care for Veterans. Measurement, Analysis, and Reports. To support the measurement and monitoring of care, VA’s new EHR-S eases access to clinical data through customizable portals and facilitates analysis via new tools for viewing and modeling information. As an ongoing function, reporting (and the potential for analysis it represents) enhances efforts to improve quality, performance, accountability, and outcomes. Health Research. The EHR-S facilitates access to research information that can be used to inform clinical care. De-identified clinical data collected during care delivery is readily available for research purposes; in turn, research findings can be integrated into the care VA provides. Patient Education. The EHR-S plays a vital role in team-based, patient-centered care, educating, motivating, and engaging Veterans in their own care. It gives providers ready access to educational materials available in varied formats and levels to best meet an individual patient’s needs and preferences, and documents the delivery of those ‘information prescriptions.’ Administrative and Financial. The EHR-S supports the management and documentation of care, while also meeting financial information needs. Clinical information is used to generate required administrative and financial information, such as scheduling encounters, providing direct support for billing, and facilitating service authorizations. Knowledge Generation. The ability of the EHR-S to leverage its vast stores of data and to link to data sources beyond VA advances medicine through evidence based methods, transforming the health record into a computationally active tool for discovery, analysis, and interpretation.
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050 2051
8.1 Measurement, Analysis, and Reports As a system, VHA works continuously to improve the quality of health care it provides to the Veterans it serves. Doing so requires rigorous measurement, analysis, and reporting of the care delivered and the outcomes achieved, all of which depend upon ready access to data that is relevant, accurate, and up to date. To this end, the new EHR-S creates huge stores of patient data gathered by VA providers, integrated with data from the Department of Defense (DoD) and private sector partners, and shared over the Nationwide Health Information Network (NHIN). Under NHIN interoperability requirements, the data meets standards that make it machine organizable and machine interpretable. Gathered in accordance with agreed upon formats and terminologies, the data are standard measures which, in and of themselves, may carry little meaning. Meaning comes through analysis, viewing the relationship or correlation of one measure (or set of measures) with another.
The power of the EHR-S comes from the ability to sift through the ever growing store of data, select relevant measures, and translate them into meaningful, actionable information.
The power of the EHR-S comes from the ability to sift through the ever growing store of data, select relevant measures, and translate them into meaningful, actionable information. The translation occurs through the use of a wide array of analytical tools, including clinical decision support and other specialized systems. What data is relevant and how the information is presented depend on the question being asked and the person asking it. Personalized Information Portals Practicing clinicians, nurses, and other providers view information from the bottom up, beginning with the anatomic data about the patient and aggregating upward to gain insight into how to treat the patient. Other professionals—for example, managers, researchers, and quality officers—view information from the top down, starting with aggregated information about groups of patients and drilling down for insight. The presentation methods used to meet these different objectives differ dramatically, but for all professionals, the level of information they can access is determined by the requirements of their positions. Personalized information portals in the new EHR-S offer a solution by accommodating differing viewer perspectives. Customizable displays and tool sets tailored to the individual user ease the process of information retrieval. A portal can ‘remember’ and thus repeat the way that a user views information, easing workflow and enhancing insight.
2052 2053 2054 2055 2056 2057 2058 2059 2060 2061 2062 2063 2064 2065 2066 2067 2068 2069 2070 2071 2072 2073 2074 2075 2076 2077 2078 2079 2080 2081 2082 2083 2084 2085 2086 2087 2088 2089 2090 2091 2092 2093 2094 2095 2096
Role-based portals for managers, researchers, and other professionals can offer customized views of the information they need to perform their work effectively and efficiently. For the quality officer, it may be vaccination rates; for the manager, effectiveness data. For providers, personalized portals can provide access to aggregate patient data for performance or process improvement initiatives, while replicating the way an individual clinician organizes the relevant information about a specific patient for each visit. This varies markedly by specialty (e.g., cardiology vs. orthopedic surgery) as well as clinician preference. Portals can also display frequently viewed parameters for similar patients of providers in DoD and the private sector Role-based portals for with whom VHA partners, enriching the potential managers, researchers, and for knowledge sharing and mutual performance other professionals can improvement initiatives. offer customized views of the information they need Graphic Displays to perform their work effectively and efficiently. The process of analysis usually involves three basic questions: What is new or has changed? What effect will this change likely have in the future? What decision pathways are likely to yield the best outcome? To ease the clinician’s workflow and ensure quality care, versions of these questions are asked and answered by the clinical decision support capabilities integrated into the EHR-S. Other VA professionals may ask new questions of the data, using trending and measuring to identify evolving performance issues and emerging concerns. For a single parameter of interest, the question what is new is probably best answered by analyzing data trended over time. Graphic displays of time-elapsed data such as new diagnoses in a population of coronary disease, correlated with cholesterol values, blood pressure data, and medication refill histories, facilitate the identification of data shifts, trends, and non-random patterns. Creating objective ways to evaluate data is important for two reasons. First, rules are useful for distinguishing normal random variation from true data shifts. Second, they guard against biases of the human mind, such as the tendency to allow recent events to influence data interpretation, or the tendency to seek confirmatory evidence in data to support initial hypotheses. Determining what is new is more difficult when there are multiple parameters over time. The challenge is to display, in a two dimensional space, deviations from normal, trends in values over time, and clustering of events. Knowing when clusters occur and what they may indicate involves data mining. Quantifying the effects of various parameters on an outcome involves statistical modeling. Both data mining and statistical modeling have enormous potential for improving the utility of the information stored in the EHR-S and its use in decision making. Clinical Predictive Models
2097 2098 2099 2100 2101 2102 2103 2104 2105 2106 2107 2108 2109 2110 2111 2112 2113 2114 2115 2116 2117 2118 2119 2120 2121 2122 2123 2124 2125 2126 2127 2128 2129 2130 2131 2132 2133 2134 2135 2136 2137
Forecasting what the effect is likely to be in the future involves predictive modeling with statistical models that quantify the risk factors predictive of specific outcomes for specific disease cohorts. For example, models have been built that predict the odds of dying, or the odds of developing numerous adverse outcomes, such as hospital admission or stroke for patients with metabolic syndrome, or the Pneumonia Patient Outcomes Research Team (PORT) score to predict morbidity and mortality in patients diagnosed with pneumonia. For clinicians, these statistical models can be embedded into the electronic health record and used to estimate the odds that their patients will develop a particular adverse outcome and to inform clinical care (such as guide a decision for admission versus home care for pneumonia). Clinical predictive models are also used to feed predictive probabilities into decision models. Decision modeling is used to answer the question ‘which decision pathways are likely to yield the best outcome?’ and is the basis for decision support systems. Decision modeling quantifies each possible choice so that the pathway that leads to the maximum expected outcome can be identified. For quality officers, predictive modeling can help identify how many adverse events are likely to occur and what the impact of various interventions may be. For population health officers, predictive modeling can help forecast and manage outbreaks of infectious diseases, such as seasonal influenza or H1N1. Integration for Transformation With the rich data stores provided by the new EHR-S, measurement, analysis, and reporting can help improve outcomes, assess performance, establish accountability, and improve quality in multiple ways. Some are basic summarization techniques that explain what the data means. Others are more esoteric, providing knowledge discovery and data mining functions. Importantly, no matter how basic or esoteric, they are readily available and integrated into the EHR-S. As a result, reporting and the analysis it represents become continuous activities rather than a periodic function. The rate-limiting factor in this endeavor has been the lack of standardization, both in how the individual data elements are recorded and what they mean amid many nonstandardized business processes. The development of clear business rules and the ability to link cost data with clinical processes and outcomes are critical to effectiveness research. As the new EHR-S provides growing access to standardized data and customizable tools for analysis, the possibilities for transformation will expand exponentially. Stopping on the way to the office to pick up coffee from the barista in the lobby of the VA Medical Center, Dr. Montes quickly views the previous day’s data regarding admissions, discharges, transfers, variances in staffing patterns, and resource and utilization trending. To others it looks like she is staring intently into space and has a slight hand tick, but she is viewing a data display only she can see. The display includes a briefing from the local public health department on the current outbreak of H8N8, population health data on diagnostic codes, and screening results for patients seen or admitted to emergency departments at the VA and across the community and tri-state area. Using gestures, she packages a subset of data and sends it to Infection Control. She’s still amazed at how small her new data device is and how quickly it has learned her gestures. Later, when she attends the morning meeting, she toggles her device’s viewer setting so she can share a display of the relevant data with her colleagues on the conference room wall or on their laptops.
2138 2139 2140 2141 2142 2143 2144
8.2 Health Research AWAITING CONTRIBUTION To launch a study of barriers to timely diagnostic testing for colorectal cancer, health services researcher Dr. Kasab accesses a mirror copy of VA’s live EHR-S that runs on a separate system for research and surveillance. Engaging a user-friendly querying option, she obtains a de-identified count of patients with positive colorectal cancer screening results in the past month. This count goes quickly because all health care providers, VA and non-VA, use the same standardized terms, and VA’s EHR-S includes all tests patients receive, both at VA and elsewhere. She revises and re-runs the query to identify patients at VA and a private facility that have given her Institutional Review Board approval to contact patients and downloads the patient contact information she needs to mail out the questionnaire to collect study measurements.
2145 2146 2147 2148 2149 2150 2151 2152 2153 2154 2155 2156 2157 2158 2159 2160 2161 2162 2163 2164 2165 2166 2167 2168 2169 2170 2171 2172 2173 2174 2175 2176 2177 2178 2179 2180 2181 2182 2183 2184 2185 2186 2187 2188 2189
8.3 Patient Education In both the outpatient and inpatient settings, providers try to educate, motivate, and engage Veterans in their own care. In outpatient settings, the EHR-S streamlines the tasks of looking for information, writing progress notes, and entering orders. With more time for personal interaction, clinicians can develop more supportive relationships with Veterans and offer them greater access to educational information. In inpatient settings, although interactions between providers and Veterans have different characteristics, the same To adjust to different three goals--educate, motivate, and engage—are [Veteran] literacy levels and present, especially at times of transition, such as learning styles, multi-media transfer or discharge. capabilities allow content to be presented in written, Relevance. To accomplish these goals in the spoken, visual, and graphic outpatient setting, the EHR-S selects problemformats. For example, a specific, educational materials linked to order sets, graph can display the consults, screening tests, and other ordering correlation between patterns. Patient education materials are a regular different data, such as component of care. At the conclusion of a Veteran medication history and visit, the EHR-S prompts providers to give the laboratory values, to a patient a comprehensive plan detailing provider diabetic Veteran. recommendations. Likewise, the EHR-S reminds the nurse or case manager to follow up with relevant and appropriate Veteran-centered education. Patient-Specific Content. A cornerstone of effective patient education, motivation, and engagement is the provision of patient-specific content. Standardized educational materials incorporate patient-specific content, such as weight, current medication lists, and prior history from the EHR-S. For diabetic patients, for example, these materials also include disease specific information, such as Hemoglobin A1C values, and dietary guidelines from their nutritionists. The new EHR-S tracks the ‘information prescriptions’ given to Veterans by providers across VA. Flexible Displays. Engaging patients in collaborative decision-making is critical to successful outcomes. Using the computer in active, dynamic ways can enhance collaborative decision-making. Patients currently view their own data in terms of trends of labs, weights, or other single variables. The new EHR-S is gradually adding new functionalities to enhance how information is shared with patients. To adjust to different literacy levels, preferred languages, and learning styles, multi-media capabilities allow content to be presented in written, spoken, visual, and graphic formats. For example, a graph can display the correlation between different data, such as medication history and laboratory values, to a diabetic Veteran. More futuristically, for example, a simulation using a life-sized avatar projected on the wall in a patient room can illustrate how a new
2190 2191 2192
and highly technical prosthetic will function. Such compelling displays can bring the plan of care to life for the Veteran, making decision making collaborative and informed.
2193 2194 2195 2196 2197 2198 2199 2200 2201 2202 2203 2204 2205 2206 2207 2208 2209 2210 2211 2212 2213 2214 2215 2216 2217 2218 2219 2220 2221 2222 2223 2224 2225 2226 2227 2228 2229 2230 2231 2232 2233 2234 2235 2236 2237 2238
8.4 Administrative and Financial Systems The new EHR-S supports event-driven and detailed interactions across clinical information and administrative systems. These interactions may be driven by administrative functions or may be initiated by defined events within the EHR-S. Integration and communication between clinical and financial applications are integral to any health care delivery system. While EHRs are largely focused on direct patient care, the health of the financial substructure, the ability to share key clinical information to support that sub-structure, and the use of datadriven metrics for analysis and decision making are critical to the health of the organization. The financial community and its associated systems support key operational functions beyond simple revenue management that can affect and improve the viability of the health care delivery organization.
The EHR-S provides an interface with administrative and financial processes that gathers timely, detailed clinical information to ensure accurate coding, billing, and reimbursement.
Supportive functions within the EHR-S allow VHA’s core clinical care processes to access the administrative information needed to ascertain enrollment, eligibility, and coverage. In addition, the EHR-S provides an interface with administrative and financial processes that gathers timely, detailed clinical information to ensure accurate coding, billing, and reimbursement. By design, the new EHR-S provides flexibility in the collection of clinical information needed to support greater accuracy in determinations of coverage. This flexibility in data collection, timely access to data, and stringent controls on data quality are all critical to ensuring appropriate allocation of these much needed health care dollars. Other administrative processes, such as authorizations, scheduling, reporting, internal controls, and financial stability, depend heavily upon interfaces to key clinical data sets. Enrollment and Coverage: These processes confirm that a Veteran is a VHA enrollee and identify in which health plan or plans, thereby ensuring that care delivered is covered. Special provisions allow for emergency care in non-VA facilities in certain conditions. The EHR-S supports multiple plans per patient, including the various VA health plans for enrollees and DoD plans such as TRICARE. The EHR-S associates each patient encounter with the appropriate health plan and uses clinically supported strategies for coordination of benefits, expediting VA’s third party billing while complying with the Health Insurance Portability and Accountability Act (HIPAA). Authorizations: These processes depend upon interactions among systems to provide the clinical detail needed for authorizations, pre-certifications, and referrals. When patient-centered care gives rise to the need for non-VA services, the new EHR-S facilitates the clinical decision making involved in authorizing outside care. Once care is authorized, the EHR-S facilitates the sharing of data by providing any necessary medical record information to the authorized provider. It also supplies modules for that
2239 2240 2241 2242 2243 2244 2245 2246 2247 2248 2249 2250 2251 2252 2253 2254 2255 2256 2257 2258 2259 2260 2261 2262 2263 2264 2265 2266 2267 2268 2269 2270 2271 2272 2273 2274 2275 2276 2277 2278 2279 2280 2281 2282 2283 2284 2285
provider to create encounter reports or results that enter directly into the comprehensive medical record. Claims forms are then linked by the fee basis provider to this evidence of service for reimbursement. By coupling procedure and service information to the initial authorization and clinical data, the EHR-S enables VA to maintain the integrity of all care provided to Veterans regardless of location of service. These capabilities facilitate utilization reviews, internal controls, and fraud and abuse detection.
Authorization processes • Facilitate clinical decision making for authorizing outside care • Maintain the integrity of all care provided regardless of location of service
Scheduling and Relationship Management: As VA health care becomes increasingly team-based and patient-centered, scheduling becomes more complicated. For example, a Veteran with diabetes who visits a primary provider at the outpatient clinic is referred to follow up with an The scheduling function endocrinologist and dietician at the medical center, within the EHR-S supports while another Veteran may need to see an interaction with other orthopedic surgeon and a physical therapist, perhaps systems and applications to in different locations. Scheduling outpatient provide necessary data for procedures, inpatient admissions, or special scheduling the right type of procedures in different locations adds another layer of complexity, as does the fact that some VA visit, with the right providers practice in more than one location. provider, in the right order. The scheduling function within the EHR-S supports interaction with other systems and applications to provide necessary data for scheduling the right type of visit, with the right provider, in the right order. Linking the scheduling function to clinical data improves workflow for the entire health care team and supports continuity of care for the Veteran. The EHR-S is able to identify relationships among providers treating a single patient, supporting the nuances of overlapping clinical responsibilities and cross-coverage. It also provides the ability to create and manage patient lists assigned to a particular provider. Reporting: The EHR-S provides standard and ad hoc reports as well as highly structured reporting. Standard reports are supported and shareable at multiple levels of the organization. Managers and executives throughout VHA have ready access to upto-date information such as enrollment and usage statistics that enable them to ensure human and material resources are sufficient and wisely applied. In addition, the EHR-S allows users to define records or reports that are not considered the formal health record for disclosure purposes, and provides a mechanism for both chronological and specified record element output. Assessment and Accountability: The ability to access and integrate information on financial health and quality of care is critical to establishing and maintaining
2286 2287 2288 2289 2290 2291 2292 2293 2294 2295 2296 2297 2298 2299 2300 2301 2302 2303 2304 2305 2306
accountability. Data mining capabilities in the EHR-S allow the VA to identify variability in purchased services, health outcomes, and community standards; this information provides the evidence base for improvements in management. Increased automation of supportive functions including access to data in the EHR-S strengthens the underlying structures that financial systems maintain. Improvements in the capacity to share data and the quality of the data allow for improved data sets that in turn enable more accurate projections of revenues and expenditures. Resource management, for example, integrates administrative and clinical data to guide decisions about the purchase of equipment and supplies necessary to health care delivery, thereby providing for better allocation of finite resources. These improvements place the VA in a stronger position to meet the growing demands for services and to fulfill the public trust requirement for responsible use of public funds. The integrity of data sets shared from clinical systems, the flexibility of those systems to meet the dynamic changes in the commercial health care industry, and the capability to more closely monitor and compare VA expenditures for health care—all are critical to the VHA’s underlying administrative and financial health. In an ever-changing health care environment, the new EHR-S and the agility it provides are crucial to sustainable and continuous improvements and to the role the VA plays in government sponsored health care.
2307 2308 2309 2310 2311 2312 2313 2314 2315 2316 2317 2318 2319 2320 2321 2322 2323 2324 2325 2326 2327 2328 2329 2330 2331 2332 2333 2334 2335 2336 2337 2338 2339 2340 2341 2342 2343 2344 2345 2346 2347 2348 2349 2350
8.5 Knowledge Generation Knowledge Generation within an electronic health management system enables the discovery of new high-level knowledge from low-level data. It introduces a powerful capability in providing individual Veterans improved health wellness and care. It also has the benefit of advancing medicine through evidence based methods on a scale and timeliness not possible by humans. The vast amounts of diverse data in VA’s massive collection of health records are leveraged to generate new scientific discovery. This provides VHA clinicians and patients information leverage directly correlating to the improvement of clinical diagnosis, causation discovery, optimal treatment and prevention of disease, and prediction of outcomes. Powerful analytics provide support by enabling the verification of human hypothesis. Doctors develop and test theories by exploiting the system’s ability to search for patterns found in health record data matching their supposition. Even more powerful is the ability of the system to discover new patterns, both Using the language of predictive and descriptive. The ability to predict statistics, knowledge with accuracy the future behavior of a patient’s, generation occurs at all non-communicable illness, communicable disease, physical levels of or even population outbreaks is possible. Perhaps medicine. most powerful is the ability to detect previously unknown but novel patterns lurking within the data, however not recognized or suspected by humans; a form of automatic discovery, analysis and interpretation by the system. Using the language of statistics, knowledge generation occurs at all physical levels of medicine: nano and molecular, cellular, tissue, biological system, patient, and population. The system tests new knowledge against historical, accounting for data noise, missing data fields and reconciling conflicts with an inherent ability to avoid or at least mitigate the challenges of over-fitting. By actively managing risk, interpretation of discovered patterns yields new knowledge and empirical laws. The system is designed to support the clinical user’s experience. It provides utility, usability and likeability. Patterns and models are communicated through intuitive graphic representation, natural language generation and data visualization methods that are cognitively supportive. Valid and useful knowledge is presented and used to seamlessly influence health choices and outcomes. Intelligent software agents act in real time to monitor the effects of treatment and the medical condition of individual patients. Serving as their advocate, the agents continuously integrate new data with old and examine progress against expected patterns of wellness and illness. Capable of managing a huge degree of data dimensionality, the system identifies and presents underlying risk factors and
2351 2352 2353 2354 2355 2356 2357 2358 2359 2360 2361 2362 2363 2364 2365 2366 2367 2368 2369 2370 2371 2372 2373 2374 2375 2376
optimization opportunities at a fine grained level tailored to the individual’s specific health related conditions. Similar agents work at the DNA level both as instruments for individual patients and for the population as a whole. Individual DNA sequence changes over time are tracked and tested against disease susceptibility. New patterns and models are created and existing ones are refined. New knowledge from the study of human genetic variability and previously unassociated data are produced. Extending beyond the boundaries of the electronic health management system, knowledge is also generated from the ability to interoperate with other systems, enabling the incorporation of an exponentially rising number of data points. Health data from other electronic records are accessed to form a more complete longitudinal record and to reduce data noise and gaps in the system data pool as a whole. Extending beyond health data, other record sources such as environmental, ethnic, occupational, geographical, meteorological and even traffic accident data are all available using natural language queries to detect patterns of causal relationships and the production of new hypothesis on the ability to better control causal conditions. Copious results are available from a wide range of viewpoints. Descriptive models to identify new cohorts, decision models yielding results forecasts, detection of side effects and the improved understandings of the relationship between exposures and mortality and morbidity are all a part of the feature set. A formal knowledge generation capability helps transform the health record into a computationally active one capable of discovery, analysis, and interpretation in collaboration with the physician. Dr. Pangarkar, a VA emergency room physician, notices that he is seeing more patients than usual with diarrhea, stomach cramps, fever, and dehydration. He speaks to Dr. Zirovich, the Chief of Infectious Diseases, and together they run a report to graph the number of patients reporting those symptoms to the hospital by date. Noting that there has indeed been a rapid acute rise over baseline numbers, they use the ‘green box’ to quickly communicate the graph and associated information to the state’s health department. The ‘green box’ also automatically sends the health department a map of the location of the primary residences of the patients presenting with symptoms, along with the date of initial presentation and initial reported symptoms. The health department notes that there appears to be a rise of cases in the entire city and forwards the information to the Centers for Disease Control and Prevention and contacts private hospitals and local city health departments seeking information on their recent patient presentations. Proactive steps are taken to identify and address the root cause, including looking into shared water sources. As stool study results become available, the system automatically sends the updated results associated with each of the affected patients to the health agencies. A citywide cryptosporidium outbreak from a contaminated water treatment plant is quickly identified and addressed much earlier than past outbreaks, thus averting potentially more cases of morbidity and mortality.
2377 2378 2379
2380 2381 2382 2383 2384 2385 2386 2387 2388 2389 2390 2391 2392 2393 2394 2395 2396 2397 2398 2399 2400 2401 2402 2403 2404 2405 2406 2407 2408 2409 2410 2411 2412 2413 2414 2415 2416 2417 2418 2419
9 Information Infrastructure The term infrastructure generally refers to the ‘bones’ of an organization’s information systems, primarily its hardware and operating system software. However, complex environments like VHA’s clinical information systems require infrastructure below the application layer to provide common services and uniform architectural support. Evolutions in functionality and sophistication of clinical applications require a corresponding evolution in information infrastructure in a number of major areas. Health Record Information Management. The ability to access, manage, and verify accuracy and completeness of information, to maintain the integrity and reliability of data, and to audit the use of and access to information—all are critical to health record management. Accordingly, the EHRS offers ways to prevent storage duplication of data in multiple systems, to identify data origins in order to assure credibility, and to balance access needs with requirements for privacy and confidentiality.
Complex environments like VHA’s clinical information systems require infrastructure below the application layer to provide common services and uniform architectural support.
Terminology Services and Standard Terminologies. Supporting semantic interoperability requires the use of standard terminologies, terminology models, and terminologies services. Long-term progress relies upon making these services ubiquitous, understanding the purpose of terminologies, and clarifying the specific instances to be supported, such as the International Classificiation of Diseases (ICD) or Systematized Nomenclature of Medicine (SNOMED). Business Rules Management. The ability to create, update, delete, and view business rules provides control of system behavior. Migrating from embedded rules in software code to higher level representations that are more visible and manageable is key to future business agility. Medical Imaging. The demand continues to increase for images seamlessly integrated into the clinical record to support the provision of high-quality care. The domain includes radiographic and non-radiographic imaging, static and dynamic images, and photographic and video imaging. This capability allows for user-generated drawings and notation. Most important, it must allow the flexibility to accommodate imaging technologies emerging now and in the future.
2420 2421 2422 2423 2424 2425 2426 2427 2428 2429 2430 2431 2432 2433 2434 2435 2436 2437 2438 2439 2440 2441 2442 2443 2444 2445 2446 2447 2448 2449 2450 2451 2452 2453 2454 2455 2456 2457 2458 2459 2460
Clinical Knowledge Management. Knowledge plays a role as a component of decision support, as a learning resource, and as a factor in promoting best practices and quality care. As such, knowledge content must be visible and manageable in the EHR-S. Knowledge includes information that is both external (e.g., clinical reference content or analogous VHA-generated content) and internal (e.g., patient data or knowledge from analysis of patient data). Registry and Directory Services. To identify, locate, and supply links for retrieval of information about providers, patients, and health care resources, the EHR-S accesses internal VA administrative registries and directories via service interfaces. Linkages with external registries, such as state and national immunization and tumor registries, require service interfaces as well.
Evolutions in functionality and sophistication of clinical applications require a corresponding evolution in information infrastructure in a number of major areas.
Workflow Management. To reduce variability of care and make better use of resources, the EHR-S provides a common infrastructure for work queues, personnel lists, and system interfaces to direct the flow of work across the health care team. Both user-centered task queue management and patient-centered clinical workflow management are integrated with clinical decision support, guidelines, and pathways. Standards-Based Interoperability. VA’s ‘systems of systems’ architecture, as well as its involvement in the Nationwide Health Information Network (NHIN), health information exchanges (HIEs), and personal health records (PHRs), all depend on standards-based interoperability. VA’s understanding of the value of standards and their technical application makes interoperability possible. Security. New approaches to authentication, authorization, and audit make security an integral part of the EHR-S. In the evolving “system of systems,” single user secure signon is critical. As the NHIN makes sharing health care information across public and private sectors the norm, VHA continues to address emerging technical and organizational challenges. User Help and Training. In support of ‘just-in-time training,’ built-in, on demand functions enhance the ability of users, from novice to super user, to efficiently and effectively engage with the EHR-S. Rich modalities offer remote help and peer-to-peer consultation and connect to knowledge management activities.
2461 2462 2463 2464 2465 2466 2467 2468 2469 2470 2471 2472 2473 2474 2475 2476 2477 2478 2479 2480 2481 2482 2483 2484 2485 2486 2487 2488 2489 2490 2491 2492 2493 2494 2495 2496 2497 2498 2499 2500 2501
9.1 Health Record Information Management “An Electronic Health Record System (EHR-S) must be able to create, receive, maintain, use and manage the disposition of records for evidentiary purposes related to clinical and business activities and transactions for an organization.” 30 Under this industry-wide definition of the EHR-S, the information management function encompasses patient-specific information, aggregate and comparative patient data, and knowledge-based information. This traditional clinical data allows health care providers and organizations to generate a complete longitudinal record of clinical patient encounters across a continuum of health care settings.
In VA’s new EHR-S, functionality that supports the health record is included along with the core clinical and foundational necessities of privacy and security.
The definition further stipulates that the EHR-S must provide a subset of data centered on a particular episode of care or encounter at any point in the record’s creation. Each record in the system must meet the standards for content, availability, integrity, and authentication described by government and industry standards and guidelines, including the Health Insurance Portability and Accountability Act (HIPAA), Centers for Medicare and Medicaid Services (CMS), Joint Commission (formerly JCAHO) and other standard-setting bodies such as American National Standards Institute (ANSI) and Health Level Seven (HL7). In VA’s new EHR-S, functionality that supports the health record is included along with the core clinical and foundational necessities of privacy and security. The privacy and security functions enable the enforcement of applicable jurisdictional and organizational patient privacy rules. As such, an authentication process verifies both the user and the level of access the user has been granted. This is accomplished through a set of permissions or role-based access controls that constrain individual access to clinical and administrative data. This control of limited access to authorized users is important for supporting the authenticity, reliability, privacy, and security of the EHR. Similarly, VA’s EHR-S enables the care delivery system to control and manage access to individually identifiable personal health information. This includes functionality to support masking patient data, redacting clinical information to protect patient privacy when releasing information, and supplying an accounting of disclosures.
30
HL7 Electronic Health Record-System Records Management and Evidentiary Support (RM-ES) Functional Profile, Committee Level Ballot Release 1, December 2007, Overview, Section 3.1 Definition.
2502 2503 2504 2505 2506 2507 2508 2509 2510 2511 2512 2513 2514 2515 2516 2517 2518 2519 2520 2521 2522 2523 2524 2525 2526 2527 2528 2529 2530 2531 2532 2533 2534 2535 2536 2537 2538 2539 2540 2541 2542 2543 2544 2545 2546
Non-repudiation remains a critical function of a legally sound record. The EHR-S supports the integrity of the data and the record, and prevents against denial of origination or receipt. This includes the use of secure data exchange, which means that information received, exchanged, or routed electronically must come from a trusted authoritative source and standards/protocols must be in place to ensure that data sent are the same as data received. The EHR-S manages information attestation, accurately identifying the author or coauthors of an entry into it. Information includes the retention of the signature attestation (or certificate of authenticity) associated with incoming or outgoing data.
The EHR-S supports the retrieval of the elements the organization considers part of its legal health record. This includes business context data (such as metadata) retained by the system, which allows knowledge of when a record or part of a record was created, and by whom.
The EHR-S supports the retrieval of the elements the organization considers part of its legal health record. This includes business context data (such as metadata) retained by the system, which allows knowledge of when a record or part of a record was created, and by whom. Organizations have a duty to preserve information that is, or could be, relevant to a legal proceeding, whether litigation is threatened or impending. Data must be preserved from normal destruction practices. Users have the ability to place a legal hold on electronic health information and prevent loss, destruction, alteration, or unauthorized use. Audit capabilities for system access and usage indicating the author, any modification, and the date and time when a record was created, modified, viewed, extracted, printed, or deleted are inherent in the EHR-S. Functionality to support work lists for compliance monitoring, such as auditing instances of copy/paste and monitoring timely record completion, are a must. Auditable records extend to information exchange, consent status management, and entity authentication attempts. Audit functionality also includes the ability to generate audit reports and to interactively view change history for individual health records in the EHR-S. Metadata authenticates the evidentiary value of electronic information and/or describes contextual processing of a record. The new EHR-S allows the flagging of data files for legal holds and will support replication of views. This can validate and quantify the authenticity, reliability, usability, and integrity of information over time and enable the management and understanding of electronic information (physical, analog, or digital). Patient care is supported if the system goes down—for either planned downtimes or disaster response. Record status must be managed during various stages of completion. It is critical that the EHR-S retains health record information created for patient care purposes even if it has not been completed or attested, was created or placed in error, was in a previous
2547 2548 2549 2550 2551 2552 2553 2554 2555
version, or has been amended. Because any information can be viewed at any given time to make a patient care decision, record changes must be transparent. The EHR-S retains previous versions of documents and manages document succession. It also provides the ability to remove an entire document from view or redact portions of it that are deemed erroneous and cite the reason for removal or redaction. The original unredacted document is maintained along with the redacted version.
2556 2557 2558 2559 2560 2561 2562 2563 2564 2565 2566 2567 2568 2569 2570 2571 2572 2573 2574 2575 2576 2577 2578 2579 2580 2581 2582 2583 2584 2585 2586 2587 2588 2589 2590 2591 2592 2593 2594 2595 2596 2597 2598 2599 2600 2601
9.2 Terminology Services and Standard Terminologies The new EHR-S is able to meaningfully and transparently gather, share, and consistently act upon detailed and contextually appropriate health information regardless of where, when, or how the information originates. By meeting difficult terminology challenges, VHA has created an EHRS that provides • • • • •
Terminologies are deployed in all production clinical applications to ensure consistency throughout the enterprise.
Complete, fully maintained content coverage Representations capable of serving at the user interface Methodologies to create unambiguous compositional expressions, Support for natural language processing Workable systems for coordinating and integrating various terminologies.
Terminology Services Terminologies are deployed in all production clinical applications to ensure consistency throughout the enterprise. Having a single authoritative repository of terminology for more than one application or system is now routine practice. It facilitates data standardization and the creation of comparable data by eliminating multiple unrecognized ways to represent the same concept and implementing approaches to compositionality that cannot be formally normalized. It also reduces maintenance costs and conflicts since updating terminology on one system is less costly and less errorprone than doing it on many. Terminology servers and services have almost completely addressed the problem of terminology access, maintenance, and data standardization. A terminology server, much like a web server, is a special purpose computer that waits for and answers terminology requests from other computer systems. For example, a billing system might ask the terminology server for the International Classification of Diseases 9th edition (ICD9) code for the term ‘hypertension.’ Terminology services support end user applications and other services, such as clinical decision support. In the latter role, they allow proprietary knowledge services to be seamlessly integrated into health information technology by providing incoming and outgoing translation services between data stores, user applications, and various knowledge bases. Standard Terminologies Support for the EHR-S is provided by an interlocking portfolio of terminologies that cover concept content for medical problems, laboratory test results, medications, procedures, and other areas that need structured data. Ongoing development and
2602 2603 2604 2605 2606 2607 2608 2609 2610 2611 2612 2613 2614 2615 2616 2617 2618 2619 2620 2621 2622 2623 2624 2625 2626 2627 2628 2629 2630 2631 2632 2633 2634 2635 2636 2637 2638 2639 2640 2641 2642 2643 2644 2645 2646 2647
maintenance efforts involve content experts, professional societies, and international standards organizations (ISOs). The portfolio provides content coverage (the availability of terms to describe current medical treatments and conditions) at a level of detail, or ‘granularity,’ sufficient to support clinical care processes. Integration efforts ensure that important areas are addressed once, without duplication or overlap, and that terminologies in different domains are used collaboratively for coverage. For example, the term for a particular medication is taken from a medication terminology; the term The portfolio provides used for the disease it is used to treat is taken from content coverage...to a terminology for diseases. support clinical care processes. Integration Content coverage is well maintained and efforts ensure that distributed in timely fashion. Processes for rapid important areas are turnaround of new terms allow end users and addressed once, without subject matter specialists to place, document, and duplication or overlap, and track requests, while also helping terminology that terminologies in experts who serve as ‘content curators’ for the different domains are used terminology with request intake, assessment, collaboratively for tracking, and end user feedback. Transactional coverage. update mechanisms expedite updates for fast changing terminologies by permitting and distributing small changes. Content curators keep abreast of important changes in their respective fields and proactively add terms based on this knowledge. Clinical terminologies reflect that the language of medicine is continually changing. New medical discoveries or new ways of categorizing known disease states constantly change the landscape. Yearly or quarterly updates are sufficient for domains with relatively low rates of change; daily updates are essential in areas such as medications with rapid rates of change. Complete content coverage is achieved in part via the application of compositional expressions. Robust clinically relevant large-scale vocabularies supply structures that support the construction of new terms whose equivalence or similarity to existing terms can be determined algorithmically. This functionality, known as ‘compositionality,’ permits the creation of new terms via the combination of existing terms and appropriate linkages. ‘Post-coordinated expressions,’ constructed by users or applications, are concepts not included in the base terminology but entirely composed of concepts from within the terminology. Permitted to co-exist with ‘pre-coordinated expressions,’ the exact nature of their overlap is determined by algorithmic processes and conceptual distance metrics with proven clinical relevance. Content curators routinely review new post-coordinated compositional expressions and consider them for inclusion as pre-coordinated terms in
2648 2649 2650 2651 2652 2653 2654 2655 2656 2657 2658 2659 2660 2661 2662 2663 2664 2665 2666 2667 2668 2669 2670 2671 2672 2673 2674 2675 2676 2677 2678 2679
the base vocabulary. Curators also use new compositional expressions as cues to new knowledge in the domain. ‘Interface terminologies‘ support the user at the point of care. In addition to offering checkboxes and drop down-lists for structured data entry, they provide an extensive synonym list of expressions that reflect actual clinical utterances and map each synonym to underlying reference terminologies and supporting informational models. In addition, they provide knowledge-based links between terms as they are used at the point of care. This enables prediction and provision of ‘Interface terminologies’ terms that are likely to be needed based on current support the user at the context. point of care. In addition to offering checkboxes and The EHR-S deploys other terminologies to support drop down-lists for real-time natural language processing that structured data entry, they captures and encodes free text entered at the point provide an extensive of care. Abbreviations are automatically translated synonym list of expressions to full words, and the usual medical semantics that reflect actual clinical written in a note are translated in the background, utterances and map each without any effort on the provider’s part, to a synonym to underlying standard terminology that, among other things, reference terminologies improves billing capture. The encoding includes novel and complex post-coordinated compositional and supporting expressions as appropriate. Key portions of the informational models. encoded data may be confirmed by the documenting clinician prior to its use for decision support, population health, or research. Formal and multi-hierarchical representations present in deployed terminologies and algorithmic conceptual distance metrics provide clinical decision support services with sufficient contextual information to deliver detailed, often individualized, knowledge to the point of care. They also support aggregations of granular data for multiple uses.
2680 2681 2682 2683 2684 2685 2686 2687 2688 2689 2690 2691 2692 2693 2694 2695 2696 2697 2698 2699 2700 2701 2702 2703
9.3 Business Rules Management
2704 2705 2706 2707 2708 2709 2710 2711 2712
The syntax for rules is constructed in different ways. One of the more common models is "If then or else ." In many cases, multiple if-then-else rules must be resolved to make one decision; in some cases, hundreds of such rules must be resolved. Other rules may be structured as "When then ." Still other rules are invoked when something does not happen such as "When then ." A single rule to support decision-making or a response may suffice in some cases; in others, a series of rules may be chained together to support more complex actions.
2713 2714 2715 2716 2717 2718
The EHR-S’ rule-model simulation offers graphical rule simulation tools to provide whatif analytics to analyze the behavior of interrelated rule models. These tools graphically create rule dependency relationships and to ensure consistency among rules. Simulated rule sets are executed against test data to see if the changes that were incorporated will work properly or have unexpected effects on the business, before going to production.
In the EHR-S, business rules management externalizes business rules so software applications do not have to be modified in response to them. This is particularly useful in complex environments like health care where rules change frequently or are shared among multiple applications. The separation allows rules to be developed, tested, and deployed on a different lifecycle from the application itself.
Business rules in the EHR-S support both human decision-making and fully automated responses.
A rule asserts business structure, or controls or influences the behavior of the business. For example, a priority group 1 Veteran is exempt from prescription co-pay. In a dynamic environment such as health care, rules must be capable of quick changes, testing, and deployment. Business rules in the EHR-S support both human decisionmaking and fully automated responses. A structured discipline, business rules management guides business rule definition, categorization, governance, deployment and use throughout the business life cycle. Additionally, it provides tools to govern who can modify a rule and when, advanced search capabilities, locking mechanisms such as check in/check-out features, versioning, and the ability to password protect a ‘final’ rule so no other changes can be made.
2719 2720 2721 2722 2723 2724 2725 2726 2727 2728 2729 2730 2731 2732 2733 2734 2735 2736 2737 2738 2739 2740 2741 2742 2743 2744 2745 2746 2747 2748 2749 2750 2751 2752 2753 2754 2755 2756 2757 2758 2759 2760 2761 2762 2763 2764
9.4 Medical Imaging The future is bright for medical imaging and its integration into clinical care. Technology is improving rapidly, providing the bandwidth and the capabilities to seamlessly incorporate imaging into VA’s EHR-S and commercial systems needed for efficient clinical workflow.
The new EHR integrates imaging into its key clinical applications, increasing efficiencies for clinicians by providing seamless access to images and video from clinical studies as well as text summaries of imaging test results.
The new EHR-S integrates imaging into its key clinical applications, increasing efficiencies for clinicians by providing seamless access to images and video from clinical studies as well as text summaries of imaging test results. In combination with the ability of clinicians to customize the information displayed in their view of the EHR, improvements ease workflow, improve communication, and quicken the care process. Providers such as orthopedic surgeons can easily access and annotate images, circle areas of interest, and add photographs to document a patient’s clinical course.
Imaging technology is growing rapidly, and many new types of images will be captured in the future. For example, optical coherence tomography is a new methodology that provides a cross section view of the retina at almost a cellular level. Surgeons are interested in surgical arthroscopic still and video images, as well as in intra-operative fluoroscopic and ultrasound images for diagnostics and measurement. Vascular angiography of the head and neck or lower extremities is of interest to a range of specialists. Cardiologists would like to store intravascular ultrasound, virtual histology, and fractional flow reserve pressure waveforms. The use of standard electrocardiogram ECG waveforms defined by Digital Imaging and Communications in Medicine (DICOM) and the continued adoption of the evolving DICOM standards will broaden VHA’s adherence to international standards. VA pathologists can link images to individual reports or specimens, make image measurements of tissue and microscopic structures, and mark image features using arrows, annotations, and labels on the captured images. Tumor board presentations can share images bi-directionally in the remote conference setting. The new EHR-S supports radiology workflow, seamlessly coordinating the Veteran’s EHR with information from radiology and scheduling packages, and expediting urgent results to the provider. With dashboards or work lists to guide workflow processes, scheduling is done by patients and staff at the point of care, and all required documentation is completed. Orders and scheduling are linked, making exceptions visible to providers and schedules to patients. . As more specialties use telemedicine to treat Veterans in areas lacking sufficient specialty care, the EHR-S facilitates clinical telemedicine service by providing work lists
2765 2766 2767 2768 2769 2770 2771 2772 2773 2774 2775 2776 2777 2778 2779 2780 2781 2782 2783 2784 2785 2786 2787 2788 2789 2790 2791 2792 2793 2794 2795 2796 2797 2798 2799 2800 2801 2802 2803 2804 2805 2806 2807 2808 2809
and easing workflow. For example, in ophthalmology, tools support remote screening for eye ailments, such as glaucoma and cataracts, and remote consultation for eye findings, with the real-time remote viewing of images to aid initial diagnosis and follow up treatment. Photographic documentation of wounds and wound healing rates is viewable at facilities that specialize in wound care. Veterans in remote rural areas or with particularly slow healing wounds can upload their own photographs of wounds from home. By allowing clinicians to view still or streaming images from a remote location, telepathology facilitates consultation between pathologists, especially with smaller facilities; teaching conferences; cancer committees; coverage for sites without pathologists or for The new EHR-S supports vacation time; consultations on biopsies; second radiology workflow, reads; and inspections. Changes in VA policy seamlessly coordinating the acknowledge the increased time required to use Veteran’s EHR with telepathology rather than onsite pathology, and information from radiology the network infrastructure is upgraded to meet the and scheduling packages, high bandwidth demands for image transfer. and expediting urgent results to the provider. Remote consultation, data sharing, and image transfer for Veterans in rural areas require access to clinical information, data stored in PDF format, ECG tracings, and lesion photos including dermatology, pathology, wound, and endoscopy images. With remote real-time or ‘as-soon-as-possible’ specialty consultation, nurse practitioner and physician assistant staffing can provide high-quality care to patients in facilities that lack specialists. As part of the Virtual Lifetime Electronic Record (VLER) initiative, VA and DoD are pursuing a joint longitudinal electronic heath and benefits record for service members, veterans, and their families. Cross facility interpretation and automatic availability of images provide joint patients with collaborative care and seamless transitions. Sharing of medical images with other government medical providers and the private sector is accompanied by acceptable privacy and security protection. Across all the specialties, imaging is increasingly becoming an integral and indistinguishable part of the EHR, not a separate application. Text, audio, image, and all digital content flow together seamlessly. The use of standard formats speeds progress, while the use of PDF integration allows the expansion of the number and kinds of modality images. The ability to store, retain, and search virtually all original images has great potential. Long-term, inexpensive, high quality storage allows the retention and use of images even if they are old. The increased and improved use of metadata with all images, as DICOM requires, allows users to search for content in VHA images. Clinicians are able
2810 2811 2812 2813
to trace the origin and course of individual patient pathology, as well as study the epidemiology for large groups.
2814 Forty-year-old Anthony Leoni suffered a career-ending injury while on active duty with the Army. For six years following his medical discharge, he went to the VA hospital in Brooklyn, New York, for treatment of the degenerative arthritis resulting from his injury. Three weeks ago, Leoni moved to Washington D.C. where he has a new apartment and a new job. Often the stress of moving can disrupt the course of health care. But not for Leoni. Shortly after moving, he visits the Washington D.C. VAMC to register at that facility. As part of routine intake protocol, his ‘new’ medical record is automatically ‘synched’ with his records at the Brooklyn VA. These contain his entire medical history including all his radiologic studies, starting from his initial DoD injury records and continuing at the Brooklyn VA, consultations, treatment history, and current treatment plan. Completed in minutes without any new forms or interviews, this electronic registration provides a comprehensive medical record that can be viewed immediately by all of his new providers.
2815 2816 2817 2818 2819 2820 2821 2822 2823 2824 2825 2826 2827 2828 2829 2830 2831 2832 2833 2834 2835 2836 2837 2838 2839 2840 2841 2842 2843 2844 2845 2846 2847 2848 2849 2850 2851 2852 2853 2854 2855
9.5 Knowledge Management Knowledge management is “the process of identifying, capturing, organizing, accessing, using and sharing the organization’s knowledge, which in turn enables people to personally and collectively become more productive, collaborative, and innovative.” 31 To become a true ‘learning organization,’ the VHA needs to understand and implement the principles of knowledge management at every opportunity. To this end, the new EHR-S incorporates knowledge management (and the linked implementation tools of decision support) in its governance, construction, oversight, and implementation. The American Productivity and Quality Center identifies seven critical dimensions of knowledge management. Through its architecture, the new EHR-S advances each of these; specifically, it does the following: • • • • • • •
Promotes communities of practice Facilitates identification and transfer of best practices Locates appropriate experts Manages content diligently Requires after-action reviews Takes advantage of lessons learned Optimizes decision support
These principles are particularly relevant in two domains: the development process and the delivery of care. Developing the EHR Optimizing the ability of the EHR-S to support knowledge management requires many elements. Of these, some are already in place and need to be preserved; others are evolving. Optimization has focused on efforts that do the following: • • • • •
31
Make the development process transparent, accessible, and discussable. Take advantage of Web 2.0 functionalities, including platforms for multi-author development, wiki-style building techniques, and social networking. Identify best practices in VHA and industrywide, to benefit from expertise in every sector as the EHR-S continues to evolve. Catalog and reference work products so the next innovator can understand how and why they evolved. Identify data provenance in all records in support of an EHR-S that integrates data from across VA, from outside providers, and from patient-generated health records.
M. Saarinen. 2007. Enabling search-drive knowledge management. KM World;S10-S11.
2856 2857 2858 2859 2860 2861 2862 2863 2864 2865 2866 2867 2868 2869 2870 2871 2872 2873 2874 2875 2876 2877 2878 2879 2880 2881 2882 2883 2884 2885 2886 2887 2888 2889 2890 2891 2892 2893 2894 2895 2896 2897 2898 2899 2900 2901
•
Implement capabilities that ‘push’ unsolicited information to users and allow them to ‘pull’ information on demand, harnessing the power of the EHR-S and linking information in the record to medical knowledge bases. • Optimize opportunities for innovation in the development and maintenance phases, fostering individual creativity and capturing it for the greater good. • Create better pathways for interaction between and among users and developers. The Veterans e-Health University (VeHU) is an outstanding knowledge management tool in this regard and needs to be continued and expanded. The new EHR-S links • Make after-action reviews the norm, using practice to knowledge as many as seven cycles of refinement to through ‘infobuttons’ and approach an optimal solution, as design related functionalities that experts do. link to a knowledge repository. Perhaps the most important challenge is the need to develop a governance structure that understands the principles of knowledge management and how governance processes can accommodate and advance them. Supporting Care Delivery One lesson about decision support is clear: unless it is incorporated in the normal work process, it is not used. The new EHR-S builds on the world’s best decision support functionality, and knowledge management provides the foundation and building blocks to enable this. From within the EHR-S, clinicians need access to accurate and current knowledge of all sorts. During a Residency Review Committee (RRC) meeting, informaticist Dr. Mitchell presents dashboard data drilled down to individual residents. He has identified a resident in Green Clinic who is showing multiple repeat visits by his diabetic patients for uncontrolled blood glucoses. Dr. Mitchell is able to retrieve the data from the blood glucose monitors the patients are using to assure that that monitors are not malfunctioning. He accesses the enterprise database center to reveal the decision support and education level set for the resident, and the RRC decides to adjust the resident’s interface settings to include additional clinical decision support. Dr. Mitchell then uses the dashboard to access a list of Green Clinic Attendings who have the best outcomes with diabetic patients and select a mentor for the resident from among them.
The new EHR-S links practice to knowledge through ‘infobuttons’ and related functionalities that link to a knowledge repository. Some knowledge is provided locally, for example, center policies, clinic schedules, directions and maps, and frequently asked questions (FAQs). Some is national, generated for the VHA as a whole, such as VHA guidelines and directives, Centers of Excellence, and active research. Other medical knowledge includes medical texts and journals, vaccination guidance, electronic databases, and search and data mining tools.
2902 2903 2904 2905 2906 2907 2908 2909 2910 2911 2912 2913 2914
Knowledge resources require information that is pertinent, accurate, and up-to-date. Cataloging, versioning, and provenance-tracking are essential, though arduous, requirements for success. As content management becomes a science, the VA is quickly developing competency in the field. To work toward best practices for knowledge management and clinical decision support in information technology across multiple health care settings and EHR technology platforms, VHA is partnering with national knowledge management consortiums, including the Clinical Decision Support Consortium (CDS-C) funded by the Agency for Healthcare Research and Quality (AHRQ) and the public-private partnership known as the Morningside Initiative.
2915 2916 2917 2918 2919 2920 2921 2922 2923 2924 2925 2926 2927 2928 2929 2930 2931 2932 2933 2934 2935 2936 2937 2938 2939 2940 2941 2942 2943 2944 2945 2946 2947 2948 2949 2950 2951 2952 2953 2954 2955 2956 2957 2958 2959 2960
9.6 Registry and Directory Services A required infrastructure element, registry and directory services are critical to successfully managing the security, interoperability, and the consistency of the health record data across the EHR-S. Using standardized Health Level Seven (HL7) interfaces, these services identify, locate, and supply links to relevant information across multiple information sources to create a complete record for each Veteran that includes care provided anywhere in VHA and outside VHA, including the Department of Defense and the private sector. Directories and registries support communication VHA’s EHR-S provides interfaces to an array of within and beyond VA’s directory and registry services, linking Veterans EHR-S. and their health care providers for health care purposes. As a fully integrated record, the EHR-S links payers, health plans, sponsors, and employers for administrative and financial purposes, again across sectors. These linkages help address issues of coverage; in combination with clinical data elsewhere in the record, they allow VA to assess cost effectiveness and improve outcomes. This latter capability is complemented by linkages to health care resources and devices, further enhancing effective resource management. Still other interfaces link VA’s EHR-S with public health agencies and disease and organ donor registries. These interfaces ensure and support the care Veterans receive individually and on a population basis. Whether they are organized hierarchically or in a federated fashion, directories and registries support communication within and beyond VA’s EHR-S. For example, a patient being treated by a primary care physician for a chronic condition may become ill while out of town. The new provider’s EHR-S interrogates a local, regional, or national registry to find the patient’s previous records. From the primary care record, a remote EHR-S retrieves relevant information in conformance with applicable patient privacy and confidentiality rules. An example of local registry usage is an EHR-S application sending a query message to the hospital information system to retrieve a patient’s demographic data. Architecture Registries typically function as common services shared by all applications, both administrative and clinical. As Martin Fowler writes in his book Patterns of Enterprise Application Architecture (2002), a registry is “a well-known object that other objects can use to find common objects and services.” In addition to consistency, this common use enhances data accuracy since errors are more likely to be caught and corrected quickly. An essential aspect of a dependable registry is a dedicated registrar staff responsible for continuously monitoring and managing the quality of data in the registry. Registry services employ sophisticated matching algorithms to uniquely identify an
2961 2962 2963 2964 2965 2966 2967 2968 2969 2970 2971 2972 2973 2974 2975 2976 2977 2978 2979 2980 2981 2982 2983 2984 2985 2986 2987 2988 2989 2990 2991 2992 2993 2994
entity to a stated degree of certainty based on a set of facts about that thing. For example, a person identification service identifies people based on demographic data elements. Registry services associate identifiers from different systems so source systems can continue to use locally assigned identifiers. This avoids the risks associated with merging records, which is extremely difficult to undo in the event of an error. Patient and provider registries include deidentification services to remove identifying information from patient and provider records before the records are sent to research or public health reporting systems.
Registries typically function as common services shared by all applications, both administrative and clinical.
Registries can also support real time location tracking system services that electronically track the location of patients, providers and durable medical equipment within a health care facility. Clinical registries are special purpose systems that identify cohorts of patients based on specific conditions or treatment regimes. These registries often contain abstracted data to support research and comparative studies. Examples of clinical registries include the tumor, hepatitis C, and spinal cord injury registries. Directory services identify entities that match search criteria, for example, which health care organizations hold records for a given patient or which health care providers provide specific types of services and are located within a given distance from a patient’s home. In VHA they are used to determine where to refer patients for specialized treatment, such as a bone marrow transplant, or to help locate VA approved nursing homes that are close to a Veteran’s own family.
2995 2996 2997 2998 2999 3000 3001 3002 3003 3004 3005 3006 3007 3008 3009 3010 3011 3012 3013 3014 3015 3016 3017 3018 3019 3020 3021 3022 3023 3024 3025 3026 3027 3028 3029 3030 3031 3032 3033 3034 3035 3036 3037 3038 3039 3040
9.7 Workflow Management The new EHR-S offers a simple, intuitive, and customizable interface that helps the provider manage information, connect with colleagues, and streamline workflow. The heart of the EHR-S design is workflow modeling that draws upon five distinct and clinically relevant domains. Interface design, input technology, system integration techniques, and information retrieval are discussed below. The fifth domain, decision support management, is covered in Section 5.5. Interface Design As the portal to the information system, the EHR-S interface connects the clinician with patient information, as well as information resources, clinical decision support, email, and multimedia. This narrows information gaps and enhances quality of care. Simple and intuitive representations of data guard against information overload and reduce the cognitive burden associated with complex data interpretation tasks. Visual displays use graphs, charts, colors, and graphical metaphors called ‘glyphs’ to highlight patterns, intervals, or changes in complex data. Using a large screen, the clinician can quickly combine displays—for example, a medication list together with a discharge summary, or lab results with order entry—to identify relationships between therapeutic interventions and clinical outcomes. ’Concept-oriented views’ aggregate information, organizing patient data around relevant clinical concepts. If the clinician chooses to review a cardiac history, for example, the EHR-S can recognize relevant content Simple and intuitive and draw together a single coherent view of pertinent representations of data diagnostic and therapeutic details. If the clinician guard against information seeks to assess the glycemic control of an inpatient overload and reduce the diabetic, the EHR-S can display blood sugar levels cognitive burden associated values plotted against insulin administration and with complex data meal times. Such views improve the clinician’s ability interpretation tasks. to recognize important events and relationships when selecting the optimal treatment strategy. Input Technology New data input modalities support medical work as a social interactive process by fostering the doctor-patient interaction and real-time documentation. New technology, leveraged to support handwritten notes, sketches, diagrams, voice recognition, and touch-screen entry, eases the capture of information at the point-of-service and supports provider preferences. Digital photos, graphs, and multimedia embedded in notes represent the diversity of physical and laboratory findings. Order entry, clinical reminder management, and other interface tasks completed at the point-of-care are automatically documented. Documentation algorithms parse unstructured narrative input and multimedia and assign metadata tags, easing later storage and retrieval that organizes information into content domains and displays concept-oriented views. Dynamic links and pointers support creation of chart indexes, hypertext links, and
3041 3042 3043 3044 3045 3046 3047 3048 3049 3050 3051 3052 3053 3054 3055 3056 3057 3058 3059 3060 3061 3062 3063 3064 3065 3066 3067 3068 3069 3070 3071 3072 3073 3074 3075 3076 3077 3078 3079 3080 3081 3082 3083 3084 3085 3086
internal cross-references. Assigned metadata support the creation of aggregate reports of chronic illness on single patients or patient cohorts for preventive care and quality control. As the EHR-S moves away from the traditional paper model and begins to approximate the interactive capabilities of a webpage, clinicians spend less time reviewing records to find fugitive, fragmented, or hidden content and more time on clinical problem-solving or bedside care. The new EHR-S platform encompasses peripheral devices that collect data and store information, leveraging patient-facing New technology, leveraged portals such as electronic personal health records to support handwritten and kiosk-based consumer software to enhance notes, sketches, diagrams, and streamline clinical workflow. Routine prevoice recognition, and appointment activities completed at patient touch-screen entry, eases interfaces are imported into the relevant sections of the capture of information the EHR and trigger decision support tools to at the point-of-service and improve clinician efficiency at the point-of-care. supports provider preferences. Digital photos, System Integration Techniques graphs, and multimedia embedded in notes Business management software and organizational represent the diversity of process knowledge are merged into the clinical interface to support workflow. Secure internal email physical and laboratory capabilities allow clinicians to transmit protected findings. health information while controlling the priority, timing, and content of the message. Clinicians can attach patient tests, clinical findings, or medical interpretations to an interoffice message to alert a colleague or solicit a consultation. Scheduling capabilities help care management teams coordinate complex activities such as surgery or cardiac catheterizations across the continuum of care. List management functions allow clinicians to create personal lists of patients for team tracking or action items for patient handoffs. Directed by patient-specific data, EHR-S workflow management systems improve clinician adherence to best-practice strategies, for example, by linking preconditions such as clinical observations and patient data to guideline parameters and generating action plans, reminders, and to-do lists. Alternative output displays now under development (e.g., flow, Gantt, and PERT charts) also promise to support complex system-based tasks, coordination activities, and therapeutic decision rules. Back-end systems (database design and program logic) support clinician workflow by intelligently managing information retrieved from disparate EHR systems or peripheral devices. Creating a medical “home” in the EHR for related data entities makes it possible to parse and integrate data scanned from legacy or non-VHA records into the new record. Physiologic data from lines, probes, and measurement devices is automatically downloaded into the vitals, procedures, or laboratory domains. The instant
3087 3088 3089 3090 3091 3092 3093 3094 3095 3096 3097 3098 3099 3100 3101 3102 3103 3104 3105 3106 3107 3108 3109 3110 3111 3112 3113 3114 3115 3116 3117 3118 3119
presentation of the full spectrum of patient health information from multiple repositories and instruments in a single display is crucial to efforts to support workflow and improve quality of care. Information Retrieval Clinicians generate multiple questions during patient encounters that can influence the trajectory of clinical care. Many go unanswered due to time constraints, the inaccessibility and unwieldiness of knowledge bases, and the Secure internal email reluctance of clinicians to interrupt their workflow to capabilities allow clinicians search for an answer they are unsure of finding. A to transmit protected growing array of technical approaches promises to health information while improve content retrieval while minimizing workflow controlling the priority, impact. One such approach involves EHR timing, and content of the ‘infobuttons,’ embedded screen buttons that use message. prediction algorithms to generate a list of links to resources and content topics based on context. A clinician selecting an infobutton while reviewing a complete blood count (CBC), for example, might be presented with links to hemaglobin lab test reference information, definitions of anemia and polycythemia, and a workup algorithm for abnormal values. As the EHR-S evolves, we can anticipate the use of artificial intelligence profiling technology to selectively filter and prioritize reference information based on user characteristics. Information repositories linked from the EHR would offer selective content filtering to predict the clinical needs of a user and rank the relatedness of available content. Providers seeking answers to clinical questions will be classified by their domain of expertise, practice location, professional background, or training level in order to predict information needs. Tailored information retrieval will improve staff satisfaction and clinical efficiency by reducing the need to sift through superfluous information.
3120 3121 3122 3123 3124 3125 3126 3127 3128 3129 3130 3131 3132 3133 3134 3135 3136 3137 3138 3139 3140 3141 3142 3143 3144 3145 3146 3147 3148 3149 3150 3151 3152 3153 3154 3155 3156 3157 3158 3159 3160 3161 3162
9.8 Standards-Based Interoperability As defined by the Institute of Electrical and Electronic Engineers (IEEE), interoperability is “the ability of different information technology systems and software applications to communicate, to exchange data accurately, effectively and consistently, and to use the information that has been exchanged.” According to the Middleton Scale developed for the Center for Information Technology Leadership, there are four levels of interoperability: (1) Nonelectronic data (paper, mail, phone calls); (2) Machine transportable data (fax, email, un-indexed documents); (3) Machine organizable data (structured messages, non-standardized content); and (4) Machine interpretable data (structured messages, standardized content). Level 3 includes un-indexed documents, objects, and images. The highest level, Level 4, includes data structured and coded using international standards.
Interoperability is sometimes segmented into two categories. The first, syntactic interoperability, is the ability of systems to exchange information; CPRS offered this type of interoperability, in its time a major advancement, but one with limitations. For the future, the new EHR-S builds on the second, semantic interoperability, which is the ability of systems to exchange and interpret data in meaningful ways.
Interoperability is sometimes segmented into two categories. The first, syntactic interoperability, is the ability of systems to exchange information; CPRS offered this type of interoperability, in its time a major advancement, but one with limitations. For the future, the new EHR-S builds on the second, semantic interoperability, which is the ability of systems to exchange and interpret data in meaningful ways. To foster this second type of interoperability, the new EHR is based on agreed upon-standards and a standards-based reference model. It provides clinical decision support that uses semantically interoperable data to generate alerts and reminders, and it shares VA information with the Department of Defense (DoD), other Federal agencies, and the private sector in ways that are seamless and meaningful. In 2009, President Obama tasked VA and DoD with the creation of a Virtual Lifetime Electronic Record (VLER) to facilitate electronic access – under proper security and privacy controls – to administrative, personnel, and medical information from the day an individual enters military service, through separation and discharge, and on through to the end of life. For VLER to truly be a lifetime record, access to records of care received from the private sector for both active duty military and Veterans is essential. Nearly 80% of enrollees have access to other health care coverage, and data indicate that most enrollees with other coverage rely on VHA for only part of their medical care. 32 32
Congressional Budget Office. 2009. Quality Initiatives Undertaken by the Veterans Health Administration. www.cbo.gov/ftpdoc10453/08-13-VHA.pdf
3163 3164 3165 3166 3167 3168 3169 3170 3171 3172 3173 3174 3175 3176 3177 3178 3179 3180 3181 3182 3183 3184 3185 3186 3187 3188 3189 3190 3191 3192 3193 3194 3195 3196 3197 3198 3199 3200 3201 3202 3203 3204
Veterans choose different combinations of care. 33 Some receive primary care from VA and specialty care from the private sector. Others choose to receive all care from VA, but must receive some contracted care for services in the private sector that VA does not provide. Under the VLER initiative, VA and DoD both maintain their own EHR systems. These systems provide critical interoperability between VA and DoD and with private sector health records through the use of Nationwide Health Information Network (NHIN) standards and specifications. A network of networks, the NHIN Nearly 80% of enrollees began as a public-private partnership to identify the have access to other health health care providers that are ready to engage in care cover, and data health information sharing with Federal partners indicate that most enrollees and each other. NHIN facilitates standards-based with other coverage rely on exchange of health information among trusted VHA for only part of their partners who have signed an agreement that medical care. specifies how participants can use data, describes the consequences of data breaches, and establishes the governance structure to sustain the NHIN. Interoperability Using the NHIN, the new EHR-S will exchange Level 4 data. This effort allows VA providers to integrate health data from DoD and private providers with VA data. The initial phase of this effort made it possible to automatically transfer lab data from private labs into VA’s EHR-S, speeding input of clinical results into the record and easing workflow. VA and DoD are extending this effort to create a meaningful and complete EHR for patients who have left active military status and are receiving treatment as Veterans. Standards The new EHR-S achieves semantic interoperability by building on the standards adopted for sharing among NHIN participants. These standards have emerged from a deliberate process of standards harmonization, recognition, and acceptance by Federal health partners and the private sector. The standards development lifecycle practiced within this private-public partnership has three main participants: the Standards Development Organizations (SDOs) such as Health Level 7 (HL7) and X12; the American National Standards Institute’s Health IT Standards Panel (HITSP); and the Department of Health and Human Services (HHS). SDOs develop standards for use in proprietary and open systems; for example, HL7’s messaging and interface standard,
33
Y Shen, A Hendricks, S Zhang, LF Lewis. 2003. “VHA Enrollees’ Health Care Coverage and Use of Care.” Medical Care Research and Review 60:253-267.
3205 3206 3207 3208 3209 3210 3211 3212 3213 3214 3215 3216
developed through a voluntary effort, is widely adopted in industry. HITSP’s role is to harmonize and integrate diverse standards that will meet clinical and business needs for sharing information among organizations and systems. The publication and use of these agreed upon standards is coordinated by HHS. Interoperability standards include content specifications, constructs that detail the standards and data elements to be exchanged with other Federal partners and the private sector. In the early phase of implementing VLER and the NHIN interoperability specifications, VA selected a highly constrained set of data elements within an XMLbased markup standard. Today VA is adding more data elements and will continue to do so until all data can be exchanged.
3217 3218 3219 3220 3221 3222 3223 3224 3225 3226 3227 3228 3229 3230 3231 3232 3233 3234 3235 3236 3237 3238 3239 3240 3241 3242 3243 3244 3245 3246 3247 3248 3249 3250 3251 3252 3253 3254 3255 3256 3257 3258 3259 3260 3261 3262
9.9 Security Seamlessly integrated security and privacy services ensure the confidentiality, integrity, and availability of health information systems supporting our nation’s Veterans. This is accomplished through an architecture of common health information security services that support all core health information applications and serve all members of the VA community, including clinicians and Veterans. Achieving this goal requires integrating existing and new systems, providing secure interactions, implementing standards, and supporting interoperability with national health care initiatives and VHA’s strategic partners. To address the challenges of complexity, scalability, adaptability, and certification, VHA is moving from an enterprise-specific, platform-focused environment to a distributed open system with standards-based security service components and protocols. Doing so reduces the complexity and costs involved in managing the systems and interfaces that support interoperability and information sharing.
Common, standards-based security controls for end-toend data sharing recognize that the VA is a participant in the broader health care community and eliminate the need for multiple accounts for individual applications.
Security Framework VA’s integrated security framework provides distributed authentication, authorization, and accountability services. Common, standards-based security controls for end-to-end data sharing recognize that the VA is a participant in the broader health care community and eliminate the need for multiple accounts for individual applications. The need to uniquely identify persons and to share information across systems is critical in health care where an integrated view of a patient – a ‘One VA’ view – is essential to patient safety and the delivery of quality care. The VA strategy is to maintain and provide shareable, reliable person information across the VA environment. Consistent application of security standards across the enterprise, including business partners, reduces costs associated with logging on to multiple systems and improves staff efficiency. The confidence of individuals in the ability of distributed networks to protect their privacy is key to achieving virtual lifetime electronic health records. VA recognizes that persons have certain controls over how their personal health care information is used and disclosed. Consent directives and other policies allow patients to express privacy preferences and to indicate what information can be shared by which clinicians, or used for treatment purposes. Distributed security services make it possible to manage and enforce security policies across the enterprise without requiring system replacement or modification. Standards-
3263 3264 3265 3266 3267 3268 3269 3270 3271 3272 3273 3274 3275 3276 3277 3278 3279 3280 3281 3282 3283 3284 3285 3286 3287 3288 3289 3290 3291 3292 3293 3294 3295 3296 3297 3298 3299 3300 3301 3302 3303 3304 3305 3306 3307
based security applications provide assurance of the security function since services only need to be certified once, and patches and hot fixes can be centrally managed and applied. Security Services Authentication. To ensure privacy, VA leverages the capabilities of ‘OneVA’ Person Identity Verification (PIV) based user identity certificates for employees, contractors and affiliates. Network Authentication Services The confidence of complete the network logon and thereafter individuals in the ability of automatically authenticate users to requested distributed networks to applications, providing single sign-on and protect their privacy is key electronic signature capabilities. Similarly, VA to achieving virtual lifetime leverages the capabilities of the Federal eelectronic health records. authentication program to provide identity assertions for Veterans. This governmentmanaged service enables single sign-on access to online government services using one ID and password. For clinicians and other users, single sign-on and features such as Medical Sign-on eliminate security as an impediment to work. Together with standards-based visual integration of health care applications at the point of use to ensure a provider is looking at information for a single patient, the new security features improve workflow efficiencies. Enterprise-wide identity and access management allow for cross-cutting user attributes/roles and self-service. Using these services enforces line-of-business, role- and use-based access control and protects hierarchical privacy and security. For Veterans, enterprise-wide identity and access management enforce individual privacy preferences and consent directives. Authorization. Access control and authorization services ensure that people, computer systems, and software applications can use only those information resources that they are authorized to use and then only for approved purposes. Access controls protect against unauthorized use, disclosure, modification, and destruction of resources. Authorization is that portion of access control management specifically involved with the granting of rights. Access control and authorization mechanisms can be identity, context, role, attribute, or rule-based. Access to protected health information is based on the roles of users in the organization and the tasks they are assigned. Under no circumstances is rigid enforcement of security constraints allowed to risk patient health, treatment, or safety. During emergency and life-threatening conditions, emphasis is placed on auditing ‘who accesses what type of information at what time,’ instead of trying to enforce very tight security constraints. In a distributed service-oriented security architecture, a network security server provides authorization credentials to users for any and all systems their roles and tasks require.
3308 3309 3310 3311 3312 3313 3314 3315 3316
Audit. Technical audit service is essential to accountability control. Accountability is the concept that individual persons or entities can be held responsible for specified actions, such as obtaining informed consent or breaching confidentiality. Audit enforces user accountability via centralized automated processing of potential security events, relating them to ‘One-VA’ identifiers for all persons of interest. Accountability is achieved through the implementation of a pervasive technical audit service that provides a record of potential insecurities irrefutably traceable back to the originator of the action.
3317 3318 3319 3320 3321 3322
9.10 User Help and Training
AWAITING CONTRIBUTION
3323
10 System Qualities
3324 3325 3326 3327 3328 3329 3330 3331 3332 3333 3334 3335 3336 3337 3338 3339 3340 3341 3342 3343
System qualities are non-functional attributes of a system that center on fitness of use in a particular context. Reliability, usability, and maintainability are examples of high level non-functional attributes. Out of hundreds of potential system qualities, those in the new EHR-S focus understandably on care providers and managers as key stakeholders and users rather than on technical operators and developers. System qualities are Resisting the temptation to create an unending list clustered into two highof desired system qualities, the EHR-S strives for level categories: runtime pragmatism. Best practice suggests system and evolution. Runtime qualities should be limited to between three and qualities involve the day-toeight, so the level of abstraction does not dilute day utilization of a into impossible vagueness. This requires tough deployed system, while choices. Desired system qualities are frequently in evolution qualities are tension with one another. Imagine wanting a fullinstilled in a system at size sports utility vehicle that gets 70 miles per gallon of gasoline, can accelerate like a rocket, design time stop on a dime, and is easy to navigate in city traffic. These are conflicting wants, and they force trade-offs. Likewise, in working trade-offs for the EHR-S, many highly reasonable qualities were necessarily omitted.
3344 3345 3346
In the final cut, the system qualities are clustered into two high-level categories: runtime and evolution. Runtime qualities involve the day-to-day utilization of a deployed system, while evolution qualities are instilled in a system at design time.
3347 3348 3349 3350 3351 3352
These qualities are global in nature, with no comparative values or scores assigned. A more detailed capability assessment is evolving to extend this work and establish EHR subsystem profiles in such areas as clinical workflow transactions, imaging, and decision support. Assigning comparative system quality scores at a sub-system level will effectively fine-tune the greater system and have a multiplier effect. It will offer much greater value than monolithic global values or no values at all.
3353 3354 3355 3356
Finally, the right blend of system qualities in a target EHR-S can strongly influence the success of that system. An optimal blend can have a transformational impact on an organization. VA’s goal for the new EHR-S is to achieve positive transformation through thoughtful system qualities.
3357
3358 3359 3360 3361 3362 3363 3364 3365 3366 3367 3368 3369 3370 3371 3372 3373 3374 3375 3376 3377 3378 3379 3380 3381 3382 3383 3384 3385 3386 3387 3388 3389 3390 3391 3392 3393 3394 3395 3396
10.1 Runtime Qualities The operational features of the new EHR-S have seven recognizable runtime qualities. Each is apparent to users while they interact with the system. Available: The system is capable of fulfilling all the functions required by VA’s health mission and of responding to user interactions on demand. All system components needed to successfully complete the business process are in an up-and-running state and within clinically prescribed timeliness parameters. Usable: The system enables users to interact easily and efficiently with the applications. Customizable user interaction is satisfying and confidently accomplished. Functions are well integrated into task workflow without unjustified complexity or inconsistencies. New users can be successful with minimal application training or technical support. Recoverable: The system is capable of restoration to a fully operational state following application or system failure. Integrity is maintained for the EHR contents and all metadata, such as audit trails. The data and metadata are not at risk of being disconnected or susceptible to corruption. Interoperable: The system provides for the easy exchange of information within a heterogeneous National Health Information Network (NHIN). Syntactic and semantic electronic health record exchanges allow for meaningful sharing of information between and among institutions and clinicians. Outbound exchange of information about VA encounters and data to non-VA providers supports care that is patient-centered and safe. Inbound exchanges are computationally interpreted by the system. Dependable: The system reliably provides correct service when exposed to failure and fault threats. Resilient to failure, it possesses self-healing and survivability features. Secure: The system offers resistance to attack and provides controls for complete confidentiality, integrity, and accountability. It functions free from risk or danger. Customizable: The system ‘learns’ the patterns of the individual user – whether novice, conventional, super user – and prioritizes its displays to those patterns. The user does not have to configure the system; rather, much like search programs on the web, the system automatically customizes what it presents to the user.
3397 3398 3399 3400 3401 3402 3403 3404 3405 3406 3407 3408 3409 3410 3411 3412 3413 3414 3415 3416 3417 3418 3419 3420 3421 3422 3423 3424 3425 3426
10.2 Evolution Qualities The evolution qualities of a system are determined during design phase. They are embodied within the structure of each system as it is built. Much like the foundation of a building, if the supporting walls are not true, the structural integrity is compromised. Accordingly, the EHR-S embodies the essential qualities identified as vitally important to enabling its evolution over its entire lifecycle. Designed to incorporate the five qualities identified as most highly desired, the new EHR-S is: Adaptable: The system is capable of readily adjusting to meet future health care needs. As Veteran circumstances change and as institutional, clinical practice, and information management practices evolve, the system can change quickly and efficiently in support of emerging expectations. Patient Centered: The system is configured and tuned to focus on supporting the everchanging health of the Veteran population, contributing to maximizing patient functionality, outcome measurement, and health value. On an individual patient basis, the system supports personal preferences, health record transparency, and manages the information such that it respects the privacy and dignity of Veterans. Maintainable: The system makes it easy to modify system faults and improve performance or any other runtime or evolution qualities. The system is ”self-aware,” with the ability to dynamically monitor, measure, and support runtime qualities. Selfcorrecting, it is free of faults, particularly computational, and thus able to support and meet its functional objectives. Open Standards Based: The system incorporates national and international standards and uses non-proprietary interfaces and service specifications wherever appropriate.
3427 3428 3429 3430 3431 3432 3433 3434 3435 3436 3437 3438 3439 3440 3441 3442 3443 3444 3445 3446 3447 3448 3449 3450 3451 3452 3453 3454 3455 3456 3457 3458 3459 3460 3461 3462 3463 3464 3465 3466 3467 3468 3469 3470 3471
11. Business Value ‘Vision Enables Strategy’ A shared vision for the use of an Electronic Health Record System (EHR-S) provides tremendous business value to the large community of stakeholders across VHA. Once the VHA stakeholders agree on the vision, the right strategy emerges. While a shared strategy is important, having a ‘vision enables strategy.’ With a clear and well The common vision defined in this document articulated vision for the provides a view of the EHR-S as a tool that future of the EHR-S, there leverages value from changes in health care can be a well defined knowledge and technology, including specific strategy to sustain the advances in medical care (e.g., precision medicine development priorities and using genomics and proteomics), clinical practice capital investments of the advances providing improved standards of care, organization. and better sharing of information through data visualization and record interoperability. This vision also includes changes in the business model to improve workflow, operations management, and communications, ensuring that Veterans obtain safe, efficient, and effective care. The EHR-S will enable improved patient schedule management and make better use of the VHA’s large capital investments in health care facilities. Costs will be better managed through an improved ability to track performance and medical outcomes for multiple cost reimbursement business models. Improved access by patients to their personal health records will be an important component of the EHR-S. Better access to health knowledge will help patients and their care providers improve outcomes. Access to information will enable better disaster preparedness and disease surveillance. Finally, large population data sets will improve the VHA’s ability to generate knowledge of health care efficacy and provide information for research studies. With a shared vision in place, VHA is positioned to develop a strategy to reach that vision. Too often organizations let their strategy drive the vision, or have multiple strategies aimed at different visions. The result is uncoordinated efforts that do not support the overall mission and projects that do not properly interface due to interdependencies not anticipated or acknowledged in the planning effort. The consequences are expenditures that fail to improve overall performance. This document articulates the vision for the future of the EHR-S at VHA and suggests some of the capabilities the strategy will provide: •
A better ability to prioritize development resources for long-term outcomes
3472 3473 3474 3475 3476 3477 3478 3479 3480 3481 3482 3483 3484 3485 3486 3487 3488 3489 3490 3491 3492 3493 3494 3495 3496 3497 3498 3499 3500 3501 3502 3503 3504 3505 3506 3507 3508 3509 3510 3511 3512 3513 3514
• •
A buildable plan with an understanding of the organizational goals for improved delivery of health care A common direction, clearly set and communicated, and adjusted as the needs evolve for EHR-S stakeholders.
To effectively capture the business value and prioritize resources for the EHR-S, VHA must develop a roadmap for the development of its major components. In addition to properly laying out the activity sequences, the roadmap establishes the organizational framework for continuously revisiting the long-term strategy to see whether adjustments are needed. With the adaptability to accommodate new ways of A key component of any effective strategy is defining workload and adaptability. Often an organization defines a delivering care, the new roadmap that cannot be implemented due to the EHR-S can improve the lack of specific skills or reliance on technology that quality of patient care in does not exist. A roadmap must be laid out in every encounter across blocks that can be built within the timeframe and VHA. budget available. It is an important quality attribute of any architecture that it is assessed at key points during the development process and throughout its entire lifecycle. Finally, the concept of ‘drift’ is important to recognize for any strategy. The initial roadmap is valid at a point in time. Over time, needs change and cause minor shifts away from the plan. This happens for many reasons. The challenge is to constantly monitor and measure the drift and then determine when and how to realign the plan with the realities of the business. With a clear and well articulated vision for the future of the EHR-S, there can be a well defined strategy to sustain the development priorities and capital investments of the organization. Without the vision, there is no underlying framework to link the value back to the patient, to the providers, and to the taxpayers. Without a clear vision for the future, the EHR-S is not sustainable. Setting the right vision is critical to capturing business value, regardless of any changes to the reimbursement model. With the adaptability to accommodate new ways of defining workload and delivering care, the new EHR-S can improve the quality of patient care in every encounter across VHA.
3515 3516 3517 3518 3519 3520 3521 3522 3523 3524 3525 3526 3527 3528 3529 3530 3531 3532 3533 3534 3535 3536 3537 3538 3539 3540 3541 3542 3543 3544 3545 3546 3547 3548 3549 3550 3551 3552 3553 3554 3555 3556 3557 3558 3559 3560
Appendix A. Brief Historical Look: DHCP/VISTA/CPRS In 1982, the Veterans Health Administration (VHA) committed to building an electronic health care architecture called the Decentralized Hospital Computer Program (DHCP). The focus was the implementation of software applications easily integrated into a complete hospital information system. VA selected MUMPS (Massachusetts General Hospital Utility Multi-Programming System) as the primary programming language for DHCP, and began developing applications using VHA programmers who worked directly with user groups in software prototyping environments. MUMPS, now known simply as “M", is an American National Standards Institute (ANSI) and Federal Information Processing Standards (FIPS) standard language. Unlike many other health care entities that focused initial automation efforts on billing and other administrative support, VHA targeted clinical functions such as Laboratory, Pharmacy, Mental Health, Radiology, and Dietetics. Key architectural and design principles adopted by the early developers included the use of mini-computers, standardization on MUMPS to ensure application interoperability, table driven reusable modules to reduce system costs and maintenance burdens, and decentralized rapid prototype development with end users intimately involved in functionality and design decisions. By 1990, VHA had upgraded computer capacity at all medical facilities, implementing software on a national scale supporting integrated health care delivery. In 1996, VHA DHCP evolved into the Veterans Health Information Systems and Technology Architecture (VistA), a rich automated environment that supports day-today operations at local VA health care facilities. VistA employs both workstations and personal computers with graphical user interfaces at VA facilities, as well as software developed by local medical facility staff. VistA also includes the links that allow commercial off-the-shelf software and products to be used with existing and future technologies. A key component of VistA is the the Computerized Patient Record System (CPRS). CPRS is an umbrella program that integrates numerous existing programs for the clinical user. Its tabbed chart metaphor organizes and presents all relevant data on a patient in a way that directly supports clinical decision-making. The comprehensive cover sheet displays timely, patient-centric information, including active problems, allergies, active medications, recent laboratory tests performed, vital signs, hospital admission dates, and outpatient clinic appointment history. This information is displayed immediately when a patient is selected, and provides an accurate overview of the patient’s current status before clinical interventions are ordered. Providers using CPRS can enter, edit, and electronically sign documents and orders. It is a true longitudinal health record that follows the patient through all VA treatment settings, outpatient, inpatient, and long term care. CPRS was initially released in 1996; its installation was mandated nationally in 1999. CPRS capabilities include:
3561 3562 3563 3564 3565 3566 3567 3568 3569 3570 3571 3572 3573 3574 3575 3576 3577 3578 3579 3580 3581 3582 3583 3584 3585 3586 3587 3588 3589 3590
•
A Real-Time Order Checking System that alerts clinicians during the drug ordering session that a possible problem could exist if the order is processed
•
A Notification System that immediately alerts clinicians about clinically significant events
•
A Patient Posting System, displayed on every CPRS screen, that alerts clinicians to issues related specifically to the patient, including crisis notes, warnings, adverse reactions, and advance directives
•
The Clinical Reminder System, which allows caregivers to track and improve preventive health care for patients and ensure that timely clinical interventions are initiated
•
Remote Data View functionality that allows clinicians to view a patient’s medical history from other VA facilities and selected data from the Department of Defense to ensure the clinician has access to all clinically relevant data available at VA facilities.
VistA Imaging is also operational at VA Medical Centers. VistA Imaging provides a multimedia, online patient record that integrates traditional medical chart information with medical images, including x-rays, pathology slides, video views, scanned documents, cardiology exam results, wound photos, dental images, endoscopies, etc., into the patient record. Bar Code Medication Administration (BCMA) addresses the serious issue of inpatient medication errors by electronically validating and documenting medications for inpatients. It ensures that the patient receives the correct medication at the correct dose, at the correct time, and visually alerts staff when the proper parameters are not met.
3591 3592 3593 3594 3595 3596 3597 3598 3599 3600 3601
My HealtheVet is VA’s award-winning ehealth website that offers Veterans, active duty soldiers, their dependents and caregivers both a personal health record and a portal that provides vetted, accurate information about health and VA benefits. For properly authorized VHA patients, online prescription refills and secure messaging with providers is available. All My HealtheVet users have access to resources and services such as food and activity journals, vitals tracking and graphing, trusted health and medical information, and healthy living centers. The Blue Button feature allows users to view, download, and print their My HealtheVet personal health information that they can then share with their health care teams, caregivers, or others. Planned enhancements include the ability to view appointments, receive appointment reminders, and view lab results.
3602 3603
VistA Impact
3604 3605 3606
A number of groups have studied VistA, including CPRS and BCMA, in attempts to document its impact on patient safety, quality of care, patient satisfaction, and cost avoidance.
3607 3608 3609 3610 3611 3612 3613 3614 3615 3616 3617 3618 3619 3620 3621
Quality of care was the focus of a 2004 study funded by a VA Health Services Research and Development grant and published in Annals of Internal Medicine. 34 Employing a cross-sectional design and a comprehensive quality-of-care measure, the study compared indicators for 596 VHA patients in 12 VHA health care systems with those for a national sample of 992 patients in 12 communities. The study used data collected between 1997 and 2000, a period during which performance measurement and electronic medical records had been implemented throughout VA’s medical system. Altogether, the study included 348 indicators drawn from national guidelines and the medical literature to address both inpatient and outpatient care, including screening, diagnosis, treatment, and follow-up activities. On average, 67% of VA patients received the care specified by the indicators, compared to 51% of the patients in the national sample. Although other factors in addition to VistA may have been involved, the fact that differences were greatest in areas where VHA had established performance measures and actively monitored performance suggests that availability of an electronic health record system was clearly a contributor.
3622 3623 3624 3625 3626 3627 3628 3629 3630 3631 3632 3633 3634 3635 3636 3637 3638 3639 3640 3641 3642 3643
A 2010 study published in Health Affairs found that VA’s investment in health information technology (IT) potentially produced $3.09 billion in net value by 2007. 35 According to the authors, all at the Center for IT Leadership, VA’s investment in health IT was “associated with significant value through reductions in unnecessary and redundant care, process efficiencies, and improvements in care quality.” Although VA did spend more on health IT than the private sector, increased adoption and use in private sector organizations will likely result in IT cost ratios equaling VA’s. The researchers found that CPRS to be “the dominant contributor to both benefits and costs” and cited CPRS’s order entry and clinical decision support functions as among the greatest benefits relative to other VistA components. They further noted VA had higher performance levels compared to the private sector in areas where VA had implemented clinical reminders, including measures of preventive care and management of key chronic conditions. Their discussion of their findings includes the following statement: “Because this study evaluated only selected VistA components, it should not be viewed as assessing all impacts from the VA’s health IT investments. Even for the components evaluated, we are aware of many potential benefits not modeled because of the lack of published studies to fully quantify the magnitude of benefits and other impacts. Therefore, the gross benefits are most likely an underestimate of the total value that the VA had obtained from its long-term investments in health IT. ” (p. 636; boldface added for emphasis)
34
SM Asch, EA McGlynn, MM Hogan, RA Hayward, P Shekelle, L Rubenstein, J Keesey, J Adams, EA Kerr. 2004. Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Annals of Internal Medicine 141(12):938-945. 35 CM Bryne, LM Mercincavage, ER Pan, G Vincent, DS Johnson, B Middleton. 2010. The value from investments in health information technology at the U.S. Department of Veterans Affairs. Health Affairs 29(4):629-638; doi:10.1377/hlthaff.2010.0119
3644 3645 3646 3647 3648 3649 3650 3651 3652 3653 3654 3655 3656 3657 3658 3659 3660 3661 3662 3663 3664 3665 3666 3667 3668 3669 3670 3671 3672 3673 3674 3675 3676 3677 3678 3679 3680 3681 3682
VistA and its components such as CPRS, BCMA and My HealtheVet have received numerous awards and other recognitions. Among them are: •
Nicholas E. Davies Organizational Award presented by Computer-based Patient Record Institute and Healthcare Open Systems and Trials (CPRI-HOST) (now part of Health Information Management Systems Society (HIMSS). 1995
•
Laureate Award presented by Computer World Smithsonian. 1995
•
Innovations in American Government Award presented by the Ash Institute of the John F. Kennedy School of Government at Harvard University. July 2006
•
Top national honors from the independent Institute for Safe Medication Practices for BCMA’s excellence in preventing medication errors. December 2009
•
A national finalist in the Consumer Empowerment and Protection Awards for My HealtheVet by URAC (formerly the Utilization Review Accreditation Commission). December 2007
•
First place in the Personal Health-Record System category at the 2009 Towards an Electronic Patient Record (TEPR) conference for My HealtheVet.
•
Phillip Longman in Best Care Anywhere: Why VA Health Care Is Better Than Yours, posits that VistA and VA have become the gold standard for efficiency in American health care. Longman argues that VA's model can and should be applied across the private sector. 2007
•
As part of its Critical Condition series on health care reform, ABC World News reported, "Study after study puts the VA system at the very top for fewer medical errors, for effective treatments, for lower costs and for patient satisfaction. And the VA delivers all of this for more than $1,500 a year per patient less than Medicare." December 12, 2007
To read more about VistA, go to http://www.va.gov/vista_monograph/
3683 3684 3685 3686 3687 3688 3689 3690 3691 3692 3693 3694 3695 3696 3697 3698 3699 3700 3701 3702 3703 3704 3705 3706 3707 3708 3709 3710 3711 3712 3713 3714 3715 3716 3717 3718 3719 3720 3721 3722 3723
Appendix B: Shared Vision Methodology In order to begin thoughtful planning for the next generation Electronic Health Record System (EHR-S), the Veterans Health Administration (VHA) convened a series of faceto-face stakeholder meetings with some of its ‘best and brightest.’ Small groups brainstormed about needed EHR-S capabilities and key principles that should guide its development and sustainment. The findings were subsequently prioritized by larger groups and, following each meeting, updated to reflect new needs and posted on a web site for VHA-wide “Vision enables strategy.” review and comment. VHA then developed an outline for the shared vision document that is a compendium of content suggested by sources such as the Health Level 7 EHR-S Functional Model standard, the HIMSS Electronic Medical Record Adoption ModelSM, and Gartner Group analysts. Selected VHA clinicians were also asked to provide feedback on the document outline to ensure inclusion of all relevant content. A VA-specific chapter grounds the EHR-S at the intersection of Veterans, government, and healthcare. VHA desires to have a ‘shared vision’ of its strategic direction for its next EHR-S. While ‘first authors’ provided initial section content, peer reviewers have added their thoughts and set the stage for contribution by all interested VHA staff. By following this collaborative approach for defining the next EHR-S, users of the resultant system will be genuinely invested in its success. The shared vision, while intentionally biased toward clinical needs, also addresses capabilities desired by stakeholders such as allied health professionals, administrative, financial, health information management, research, and education staff. Subsequent implementation activities—conceptual designs, business prioritizations, requirements definitions, and organizational developments—will drive VHA toward attaining this vision. Following the open review and comment period, the shared vision will be finalized and formally presented to key groups and organizations within VHA. An Executive Decision Memorandum will then be presented to the Under Secretary for Health. His concurrence will ensure appropriate consideration of the shared vision in VHA’s strategic and tactical planning processes. Further refinement of the future EHR-S capabilities will take place in a series of conceptual design sessions where key clinical user interfaces and workflow will be explored.
