Department of Veterans Affairs

VistA

EvolutionImplementation

Case Studies

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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:– 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

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Cover Sheet

Clinical Intervention Applications

CPOECPOE

active problems, allergies, current medications, recent laboratory results, vital signs, hospitalization

and outpatient clinic history

active problems, allergies, current medications, recent laboratory results, vital signs, hospitalization

and outpatient clinic history

narrative notes entry

and browsing

narrative notes entry

and browsing

Lab resultsLab resultsMedication

administration

Medication administratio

n

AlertingAlerting

Medical image

browsing

Medical image

browsing

Evidence-based clinical

guidance

Evidence-based clinical

guidance

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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Bar Code Medication Administration• Inspired by handheld

device used at rental car return

• Sue Kinnick, nurse in Topeka, KS, built prototype with developers

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• Scan patient, nurse, and medication• Alerting if wrong med, dose, patient, or time• Now the standard throughout the US

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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 CoordinatorCAC Recipe for Success*

• Technology 10%• Clinical medicine 10%• Sociology and people 80%

*attributed to Homer Warner

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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)

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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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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.

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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

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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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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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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