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Health IT Strategic Framework

Attachment 2


V. Other VA Approaches - Knowledge and Technology Transfers to Benefit Target Populations

VA is a leader and innovator in the development of electronic health records, such as present system VistA and CPRS, as well as planned future systems HealtheVet-VistA and re-engineered CPRS. VA already has realized the target benefits of adopting EHRs and therefore is well-poised to participate in the expansion and integration of such technologies to larger health communities.

The universe of VA health care encompasses approximately 1300 sites of care that include 158 hospitals, over 850 community-based outpatient clinics, as well as nursing homes, domiciliaries, Vet Centers, and residential rehabilitation treatment programs. VA provides treatment to almost 5 million veterans each year among our 7.5 million veteran enrollees, who are older, sicker, and poorer than the age-matched U.S. population. This feat is made possible by VistA and other electronic health technologies.

Much of VA's VistA system was developed by VA government resources and therefore, the software exists in the public domain. Through on-going and active collaborations with a number of government and private-sector resources, VA encourages the proliferation of public domain technologies based on VistA code. This approach reduces expensive development costs associated with software and human capital requirements, and makes proven EHR technology an affordable and direct-transfer option to rural and medically underserved communities.

In addition to health information technology development, VA is a leader in large scale health information system implementation without compromise to patient safety or medical care. To the contrary, VA system implementation has improved the quality of care in measurable ways due, in large part, to data made available by VistA. As a result of this extensive system implementation experience, VA has also learned important lessons about the challenges of applying new technologies to existing clinical environments. VA has successfully taken a legacy system, the Decentralized Hospital Computer Program, and transformed it into modern VistA. A future version HealtheVet-VistA will soon be available and our public domain version of VistA, HealthePeople-VistA, is growing through national interest and collaboration opportunities.

VA shares these lessons in a number of forums. The following are examples of VA health information technologies that should be considered for coordinated knowledge and technology transfers to support these populations.

A. VistA for Use in Office-Based Practices and Clinics

In cooperation with HHS, VA is presently developing a public domain electronic health record based on core VistA technology. This project, will develop a product for release, within the next 12 months that will be suitable for use in office-based practices and clinics, and for use in collecting quality measurements of health data. As public domain software, this VistA-based tool will provide an affordable option for technology acquisition by decreasing resources necessary for installation and maintenance and will support the delivery of health technology benefits to all Americans. Planned enhancements include a) enhancing the registration capabilities of the VistA product to meet the needs of clinicians in office-based practices and clinics , b) enhancing the OB/GYN and Pediatrics components of current VistA, c) simplifying VistA so that its installation and maintenance is easier, d) improving the management of chronic diseases and e) providing for communication of outcome measures to a Quality Improvement Clinical Data Warehouse. Such a tool may be adopted directly by physicians and clinics, or acquired by private sector entities that support them.

Other on-going examples of public domain technology transfers that could benefit rural and medically underserved communities, as well as the larger health community, are included in Appendix E.

B. My HealtheVet - The Personal Health Record

Personal health records are an important component of the provision of health information technologies. Personal health records provide patients the tool to collect and maintain personal health information and encourage active involvement in health care decisions that impact them. On Veterans Day 2003, VA released Phase 1 of My HealtheVet, a personal health record tool for veterans. Functional capabilities include: secure personal health journal, 18 million pages health and wellness information, benefits information, and online drug interaction checker. Future capabilities will include: online primary care appointing, Web-based pharmacy refill and renewal, appointment reminder, structured provider to patient messaging, and secure provider access to CPRS/VistA.

My HealtheVet will transform the delivery and management of care into a collaborative venture as veterans will eventually choose to share all or part of their information with family members, health advocates, or other private health care providers. This forward-thinking concept, that veterans are active participants, partners, and managers of their own health care, should be highlighted and explored for application to target communities.

C. Bar Code Medication Administration

Within hospitals, medication administration errors lend a substantial contribution to the rate of morbidity and mortality. One innovative technology developed and utilized by VA to address this is the VA Bar Code Medication Administration System (BCMA). BCMA was developed based on a prototype project created at the Colmery-O-Neil Veterans Affairs Medical Center. BCMA is a wireless, point of care technology that uses an integrated bar code scanner. The bar scanner permits nurses to scan patient wristbands and medications while the software "checks" the transaction and validates what was given against the electronically stored order. BCMA ensures that each patient receives the correct medication and dose at the correct time by eliminating the need for reliance on short-term memory. BCMA technology will alert the nurse administering a medication if the software detects a mismatch between the identified patient and ordered medication dosage, time, or drug. Order changes and updates are electronically communicated to the nurse thereby eliminating time delays and increasing administration accuracy. Allergies, adverse reactions and special instructions also are tracked by BCMA as well as order changes that require staff attention. BCMA is fully compatible with VistA and CPRS.

VA-developed BCMA technology could greatly improve the efficiency by which care is delivered in hospitals and other settings across sites. Benefits include:

  • Increasing accuracy of medication administration;

  • Increasing the information available to clinical staff at the patient point-of-care;

  • Reducing wasted medications;

  • Improving communication between Nursing and Pharmacy staffs;

  • Providing a real-time list of orders for medication administration;

  • Recording refused and held medications and reasons;

  • Recording missing doses and sending the request electronically to the Pharmacy; and

  • Providing a point-of-care, real time data entry/retrieval system.

D. Telehealth/Telemedicine

Telehealth makes up a significant component in how VA intends to fulfill its mission to care for veteran patients. Telehealth involves the provision of health care services when patient and provider are separated in time and/or place, and take place using electronic media. Telemedicine is included within the broader rubric of telehealth. Within VA, telehealth transactions most often involve care between all professional groups and patients, not just physicians. The expansion of telehealth is an important part of the mission of VA, and directly supports coordinated delivery of care.

There are significant clinical and business barriers to the expansion of telehealth services that VA is addressing. For instance, outside of federal health care delivery locations, state licensure requirements often prohibit practice of medicine or nursing across state lines. Inadequate coding and reimbursement structures are examples of business barriers to telemedicine expansion.

The computerized medical record is a critical component to VA's strategy for the expansion of telehealth. For example, using videoconferencing to connect a patient with a provider situated many hundreds of miles away could not take place safely and effectively without having the patient's health record, laboratory results and clinical images available. This transaction would be of greater benefit if the medical record existed in multi-media format.

The concept of telehealth in VA is absolutely congruent with VA's transition to a computerized patient health record from a computerized patient medical record. This record is currently configured to operate within the context of clinics and hospitals. VA is working to expand the concept of the multi-media record into the home using home-telehealth technologies and My HealtheVet. In VA, technology is not the driver; rather, technology is supportive of the way in which VA meets the changing nature of the health needs of veteran patients. Veteran patients have predominantly chronic diseases that are being treated in non-hospital settings. VA telehealth is expanding to meet these needs in the settings where they are needed most.

E. VistA Imaging Technology

The VistA Imaging System is a system that enables the sharing, storing and retrieval of clinical images. VistA Imaging is a critical component to the VA vision of the multi-media patient health record; it will support both conventional and telehealth-based health care delivery.

VistA Imaging is a VA developed tool that integrates traditional medical chart information with medical images of all kinds, including x-rays, pathology slides, cardiology motion views, wound photos, and pictures acquired during endoscopy, surgery, and eye exams. Document scanning incorporates handwritten records, diagrams, and outside medical reports in online records. VistA Imaging permits a remote consulting physician to have access to clinical images for diagnosis and treatment - an invaluable tool for the provision of care to remote rural and medically underserved populations. VistA Imaging workstations are deployed throughout VA hospitals to capture and display medical images from across multiple specialties. VistA Imaging also uses the Digital Imaging and Communications in Medicine (DICOM) standards to interface directly other imaging equipment including CT, MRI, Ultrasound and X-ray.

F. Support of Community and Regional Setting Broad Data Exchange Initiatives

VA presently participates in a number of data exchange initiatives that involve community-based private or government organizations. Although VA is not exchanging data with these organizations per se, close collaboration provides invaluable technology transfer and data exchange lessons (e.g., data security and patient privacy lessons) in settings where they are needed, improving patient care to the those populations within the communities and serving as a framework model of collaboration that other communities could replicate. Examples of on-going data exchange initiatives are included in Appendix F.

G. Contracting Incentives With Private Providers

As a purchaser of clinical services, the Federal government contracts with private sector providers to deliver care to its covered lives. In developing contracting incentives with private providers, initial activity within VA will include assessing all contracts for covered care. Potential benefits to be gained from incentives for use of health IT within these contracts include gains in quality and efficiency in caring for covered veterans. VA recognizes strong similarities between the use of incentives within contracting and the incentives within reimbursement. In an effort to foster strategic alignment and to decrease the risk of multiple Federal incentives methodologies impacting the VA business partners, VA will explore aligning its contract incentives with the reimbursement incentives as established by CMS, DoD, and other Federal agencies.

Last revised: July 28, 2004

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