Transcript The doctors at Jesse Brown cannot imagine working without - hi-600

Department of Veterans Affairs
VistA
Evolution
Implementation
Case Studies
4/9/2016
Group 2: Farabaugh, Jordan, Katzovitz, Odom
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History of the Veterans Administration
• Established in 1930 to provide care for war veterans
– Started with 54 hospitals
• Today, the VA serves as the largest integrated health
care system in the U.S. for Veterans.
– Number of patients increased by 29% in 2008
– 4.5 million in 2001 to 5.5 million in 2008
• Currently the VA has:
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153 medical centers
909 ambulatory care and outpatient clinics
135 nursing homes
47 rehabilitation treatment programs
232 veterans centers
Focus on Quality
• 1960s-70s: VA heavily criticized for its quality
of care
– Complaints from Vietnam veterans
– Unhappy staff
– Congressional concerns and complaints
Computer Technology
• Computer technology controlled by the Office of
Data Management and Telecommunications
(ODM&T) in late 70s
– Used large mainframe computers
– Largely vendor used software
– Poor performance and lack of inoperability
– Time consuming development of applications
Origins of VistA
• Medical professionals began to develop their own
software in response to ODM&T lack of quality
– Known as the Hard Hats
– Used MUMPS language
• “The database we chose was called MUMPS. It is really an
old clunky program, but it proved to be a very good program
to hone into an individual patient chart. It drills down
information very quickly into one file. However, it is not good
at cross referencing the same field in multiple charts. We
started with this and did quite well.” (Dr. Lewis Coulson, Jesse
Brown VA, Illinois)
Origins of VistA
• Computerized Assisted System Staff (CASS)
– Development of the DHCP
• Backlash from ODM&T and private-sector
– ‘Underground Railroad’ movement
• DHCP written into law as the information
systems program for the VA in 1981
– Implemented nationally by 1989
– Became known as VistA in 1996
VistA Today
• VistA architecture underpins hundreds of
applications
– CPRS
– VistA imaging
– Barcode medication administration
– My HealtheVet PHR
– …and many more
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CPRS
• Computerized Patient Record System
• GUI EHR: “umbrella program” that integrates a
number of clinical applications in a common
graphical user interface with a “tabbed chart
metaphor”
• Solved issues of multiple logins and need to
access multiple programs to gather patient
information
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CPRS Workflow
Cover Sheet
Clinical
Intervention
Applications
Evidencebased clinical
guidance
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active problems, allergies, current medications,
recent laboratory results, vital signs, hospitalization
and outpatient clinic history
CPOE
narrative
notes entry
and browsing
Alerting
Lab results
Medication
administratio
n
Medical
image
browsing
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CPRS Development
• Done in concert with clinical process redesign
• “If the VHA clinicians had simply computerized
existing workflow processes, the significant
efficiency improvements that the VHA has
demonstrated over the past seven years
would not have occurred” (Evans, et al., 2006)
• Clinical Applications Coordinator role
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Group 2: Farabaugh, Jordan, Katzovitz, Odom
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Bar Code Medication Administration
• Inspired by handheld
device used at rental car
return
• Sue Kinnick, nurse in
Topeka, KS, built prototype
with developers
• Scan patient, nurse, and medication
• Alerting if wrong med, dose, patient, or time
• Now the standard throughout the US
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4/9/2016
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Clinical Application Coordinator
• Clinically Experienced
• Supports clinicians and IT staff in the adoption
of technology
• Training
• Administrate user set-up
• Innovate
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Clinical Applications Coordinator
CAC Recipe for Success*
• Technology 10%
• Clinical medicine 10%
• Sociology and people 80%
*attributed to Homer Warner
4/9/2016
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Clinical Applications Coordinator
“Doctors are not very specific, they talk in generalities. The
programmers don’t ask enough questions they just start
writing code. I had my assistant, Betsy Levin who was one of
the first CAC’s in the country. She was not a programmer, but
we taught her how to do some things. She learned how to
talk to programmers and speak their language, then get back
to the doctors. The CAC’s I currently work with are a nurse,
social worker, speech therapist, and lab tech. All have different
backgrounds and can think about patient care. You have to
have an intermediary who can do these types of things; they
are the most important person in the equation. Don’t train
the CAC’s to do the programming, they just have to talk the
language, and be patient with programmers.” (Dr. Lewis
Coulson, Chief Ambulatory of Care & Strategic Planning, Jesse Brown VA)
4/9/2016
Group 2: Farabaugh, Jordan, Katzovitz, Odom
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VistA Challenges & Issues
• August 2008 to Dec. 2008 Medical data errors
• Poorly planned capital projects – RSA
• Decentralization vs. Centralization
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Group 2: Farabaugh, Jordan, Katzovitz, Odom
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Interoperability: DoD and VA
• Wounded Warrior Act of 2007
– “develop and implement a joint electronic health
record (EHR) for use by the DoD and VA as well as
accelerating the exchange of health care
information between the two departments.”
• September 30, 2009 deadline for
interoperability
• Did they make it? Depends on who you ask.
4/9/2016
Group 2: Farabaugh, Jordan, Katzovitz, Odom
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QUERI System
• Quality Improvement Initiative
• Follows a 6 step process
• Identify high priority diseases, apply clinical
interventions, and document outcomes
improvements
4/9/2016
Group 2: Farabaugh, Jordan, Katzovitz, Odom
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Jesse Brown VA
• VA Hospital in Chicago
– 188 Beds
– 7600 Inpatient admission
– 531,000 Outpatient visits
– Budget $235 Million
– 1,000+ VistA users
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Jesse Brown VA
“The doctors at Jesse Brown cannot imagine
working without VistA/CPRS. When we have
planned system downtime most users hold as
much of the work they need to do until the
system is back up.” (Laurie Blum-Eisa
Interview 2009)
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Group 2: Farabaugh, Jordan, Katzovitz, Odom
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Jesse Brown VA
• Data stored three locations
• Down-time
• System features most proud of at Jesse Brown
– BCMA
– CPRS clinical reminders
– Remote data
– Imed Consent
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Group 2: Farabaugh, Jordan, Katzovitz, Odom
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Midland Memorial Hospital
• VistA implementation in private institution
• Small, 371-bed community hospital
• Goal to replace systems with a complete EHR
Midland: Implementation
• Chose Medsphere’s OpenVista
• Contract in late 2004
• Implementation began in early 2005
– Software reconfiguration included changes to GUI and
enhancements specific to facility needs
• Clinical configuration began in summer 2005
– Clinical IT team formed
• Go-live in June 2006
• Paper charts removed February, 2007
Midland: Cost
• Budget was a major factor in selection
• Midland had a $6.3 million budget
• Average cost for proprietary system in 2003
was between $18-20 million
Midland: Success
• Staff can now efficiently access entire records
• Decrease in medication errors, patient deaths,
and infection noted since implementation
• Permanent records offer legal protection
• HIMSS Stage 6 ranking for electronic health
record