Enabling Health Care Efficiencies via an Interoperable Health Record

Paul TibbitsDeputy CIO for Enterprise DevelopmentDepartment of Veterans AffairsNovember 12, 2009

Interoperability: Current and Planned

3

Current State

KEYKEYCurrent Sharing (Viewable)

Planned Sharing (funded)

Potential Sharing (unfunded & uncosted)

Current Sharing (Computable)

Potential Sharing (VA funded; DoD identified funding requirements – FY09 supplemental)

On Contract

Potential Sharing (DoD funded)

BEC IS/IT WORK GROUPBEC IS/IT WORK GROUPHEC IM/IT WORK GROUPHEC IM/IT WORK GROUPAccessions & Separations

Combat Military Pay

Activation / Mobilization

MGIB Eligibility Information

Add’l Education Benefit Data

UIC Mailing Address Data

Military Pay Information

Insurance/ Benefit Eligibility

MGIB Program Usage Data

Military Service Imaged Record via DPRIS

Compensation & Pension Data

Member / Veteran Family Member Information for Insurance and Cemetery Benefits

Defense Center of Excellence

(DCOE)

Research Clearing / Data-

mart (LOA2)

TBI Patient Registry (LOA2)

TBI / PTSD Telehealth

Consult (LOA2)

Phase 1 of Common

Services Initiative

Phase 2 of Common

Services Initiative

Non-Clinical Case Mgmt.

(LOA3)

Web-Based FIRP (LOA3)

VA Disability Exam Templates

(LOA1)

Imaging - Theater (LOA4)

Reserve Health Records Access

(LOA4)

Cognitive Assessment Tool

(LOA2)

Clinical Enhancements

Web-Based Training (LOA2)

TBI Extender Codes (LOA2)

Behavioral Health Notes

(LOA2)

Plan Completed Jun 08

Images (Enterprise-Wide)

DoD and VA Shared Health

Data

Post-Deploy Reassessment

Std Ambulatory Data Record

Problem Lists

Additional Inpatient Data

Discharge Summaries

Post-Deploy Assessment

Procedures

Vital Signs

Allergy Data

Radiology Reports

Operative Reports

Other History

Pharmacy Data

Inpatient Consults

Theater Clinical Data

Social History

Pre-Deploy Assessment

Lab Results

Provider Notes

Family History

Questionnaires

Interoperability Plan, V 1.0 Completed Sep 08

Add’l Data Elements (Viewable)

Add’l Data Elements (Computable)Sep 09

Sep 09

Sep 09

Sep 09

Oct 09

Document Scanning (initial)

Inpatient Documentation Expansion

Gateways - Data Migration

Expansion of Questionnaires

Lab Results (computable)

Plan Completed Jun 08

Interoperability Plan, V 1.0 Completed Sep 08

Images (Enterprise-Wide)

Add’l Data Elements (Viewable)

Add’l Data Elements (Computable)

DoD and VA Shared

Personnel / Administrative

Data

eBenefits Portal (LOA4)

Dis Eval Sys Pilot - VTA Tracking

(LOA1)

Wounded Warrior Indicators (LOA4)

Clinical Case Mgmt. (LOA3)

ADT to DFAS (LOA8)

Document Mgmt. System

(LOA1)

4

North Chicago – Captain James A. Lovell Federal Health Care Center

• First FHCC managed jointly by VA and DoD

• Opening Day October 2010

• On Schedule• Provide Information

Management/Information Technology

• Key to establishing VA/DoD electronic health record

Ambulatory Care Center site

Other Government Agencies

Other Government Agencies

Beneficiary / StakeholderBeneficiary / Stakeholder

Managed Care / Fee Private Providers

Managed Care / Fee Private Providers

5

DoD VACommon Services

DoD Unique Data Ex: Enrollment, Operational/Theater Information

VA Unique DataEx: Extended Care Data, Veteran/Dependent Benefits

Proposed Future State

Accession

Training

Readiness

Deployment

Education

Personnel

Data Compensation

Medical Care:

Theater &

Home

Separation

VA Extended

Care

Memorials

Survivor

Benefits

Army

Navy

Marine Corps

Air Force

JOINT

Health | Benefits | Personnel

Virtual Lifetime Electronic Record

VHA

NCA

VBA

Identity Management

Self-Service Logon

Compensation

Benefits & Eligibility

Education

Portable Order Entry

Single Sign-OnPharmacy*

Consults

Lab*

Radiology*

Service History

Other Uniformed Services

Other Uniformed Services

* Orders and results

Nationwide Health Information NetworkHealth Bank or

PHR Support Organization

Community #1

IntegratedDelivery System

Community Health Centers

Community #2

CDC VA

CMS

DoD

SSA

State and Local Gov

Labs

Pharmacies

The Internet

Standards, Specifications and Agreementsfor Secure Connections

Mobilizing Health Information Nationwide

Architecture and Technical Challenges

Top 10… SOA General Misconceptions

10. Orchestration = dynamic discovery = dynamic consumption9. Configurable = loosely coupled8. Identity is Identity, and there is only 17. SOA is a “Big Bang Theory”6. Granularity of services is easy to define5. Standards and Specifications compliance is strictly defined4. WSDL exchange = interoperability3. Security and auditing can be retrofitted2. Service-Oriented Architectures are primarily a technical or

management approach

And the #1 General misconception is…1. SOA is the answer to interoperability (and you can buy one)

Approaching Service Orientation• Strategic Governance needs to

enforce the “design by standards” approach versus “design by product” across the Enterprise

• Critical elements required to scale Tactical Governance Model

– Enterprise review boards– Programmatic Governance

Boards: Enterprise Management Processes

– Functional Governance Boards: portfolio and capability establishment

– Technical Governance Boards• Roadmap for core services

utilized by all development efforts

• Reference Architecture to enable experimentation and development including Standards, Specifications, Patterns and Practices (SSPPs)

VA Internal Use Only 9

FEA

Infrastructure Components

Information & Data

Applications

Services

Business Components (Functions, Sub-functions, and Capabilities

Strategic Goals & Objectives Eight for

Excellence

Eight for Excellence

VHAVHA

Domains of Value

Domains of Value

MedicalResearc

h

MedicalResearc

h

MedicalCare

MedicalCare

MedicalEducatio

n

MedicalEducatio

n

Care MgmtCare Mgmt

EmployeeHealth Record

EmployeeHealth Record

Sub-Function

1

Sub-Function

1

Sub-Function

2

Sub-Function

2

Sub-Function

3

Sub-Function

3

Sub-Function

4

Sub-Function

4

Information Element 1

Information Element 1

Service 1Services

2Service n…

Service 1

Service 3

VBA Service 4

NCAService 6

Composite Apps

Messaging

Discovery Security

Core Services

BRM

DRM

SRM

TRM

PRM

ESM

Information Element 3

Information Element 3

Information Element 4

Information Element 4

Information Element 2

Information Element 2

Information Element 5

Information Element 5

Information Element 6

Information Element 6

VBAVBA NCANCA

VBAStrateg

y

VBAStrateg

y

NCAStrateg

y

NCAStrateg

y

VBALines of Business

VBALines of Business

NCALines of Business

NCALines of Business

VBABusiness

Area

VBABusiness

Area

NCABusiness

Area

NCABusiness

Area

VBASub-Functions

VBASub-Functions

NCASub-Functions

NCASub-Functions

VBAInformation

Element

VBAInformation

Element

NCAInformation

Element

NCAInformation

Element

VBAService

6

NCAService

6

VHAService

VBAService

VBAService

NCAService

VBAService

NCAService

E-SOA Governance

VA Pillars Governance

RequirementFramework

RequirementFramework

OrganizationalGovernance

OrganizationalGovernance

OpenCommunity

Process

OpenCommunity

Process

BusinessProcess Modeling

BusinessProcess Modeling

Data Strategy

Data Strategy

MetricsMetrics

Test &Assessment

Test &Assessment

Certification &Accreditation

Certification &Accreditation

DeploymentStrategy

DeploymentStrategy

Education &Training

Education &Training

Technical Standards

Example: Chapter 33 Tactical Governance• Implementing Governance for Chapter 33

– Established OED / Chapter 33 Architecture and Engineering Governance Board– Established ESOA / Chapter 33 Architecture Integrated Product Team (IPTs) to

manage issues in key areas• Security, Architecture, Infrastructure

VA Internal Use Only 10

ESOA / Ch 33 Arch IPT Charter

OED / Ch 33 Arch-Eng Governance Board Charter

SPAWAR (Chair)Ch 33 Technical Team

VBA-SEEIE

OED-SE

OED-SE (Chair)VBA Architect

PM RepEIE Rep

BOIBI RepField OpsSecurity

• Identifying and managing critical gaps in Governance for Chapter 33

– Process and artifacts that:• Identify connection to systems outside CH33• Determine responsibility for changes to these

systems• Determine service agreement type• Enable CH33 service deployment and

certification

• Developing service-oriented Standards, Specifications, Patterns and Practices (SSPP) and an associated reference implementation of core services

Chapter 33 Tactical Governance

Chapter 33 Governance Model is scalable to the Enterprise level

Innovation

Innovation Components

Greenfield Incubation—field innovators propose new opportunities

Strategic Incubation*—leadership identifies opportunities Innovation Diffusion—evaluation of the quality of products

and how products work in the healthcare delivery process Collaborative Tools—technologies used to advance

innovation and encourage the building of communities of interest

Workforce Development—activities undertaken to build a culture of innovation and a knowledgeable workforce

VA OI&T Innovation Advancement Program (IAP)

*cross-Administration strategic initiatives to be undertaken; points of contacts have been identified

12

Innovation Evaluation• Innovation criteria

– Improves patient care (e.g., safety, quality or access)– Improves efficiency (e.g., clinical workflow or cost/benefit)– Impacts numerous Veterans, staff or other stake holders– Addresses an unmet need rather than incrementally improves existing methods– Helps meet an organizational requirement (e.g., Joint Commission or Congressional

mandate)

• Three review teams, five reviewers per team with multi-discipline and leadership level mix

• Preliminary Review Process:– Addressed Conflicts of Interest – Randomly assigned LOI to teams– Used blinded independent review with established Innovation Evaluation Criteria on 1-5

scale– Group discussed and determined final scoring

• Final Review Process and Criteria: – Same review teams, evaluated full proposals– Benefit factors: Quality, Efficiency, Scope, Novelty, Requirement– Feasibility factors: Team, Approach, Environment

Greenfield Award Overview

Category

Reviewed LOIImpactingCategory

AwardsImpactingCategory

AwardPercent

Administrative 114 29 25%

Clinical 159 43 26%

Education 56 21 38%

Other 34 9 26%

Veteran Direct Impact 124 36 29%

44 TOTAL CONCEPTS SELECTED FOR FUNDING

Program Management and Acquisitions

16

Analysis of Ongoing VA Programs

• 280+ programs reviewed• 8 program attributes analyzed• Many programs exhibited signs of trouble

– Greater than 13 months behind schedule– Greater than 50% over initial cost estimate– Decrease in software quality between releases– Inadequate skills to complete program

• Substantial change required

17

Incremental Development

• All new VA IT projects/programs must use an incremental development approach– Frequent customer delivery milestones at maximum of six months– Customer must test and accept functionality

• To be approved for investment, a program or project must have:– An identified customer sponsor and integrated project team (IPT)– Program plan that documents frequent delivery milestones– Documented, agreed to requirements for initial milestones– Clear plan for necessary program disciplines– Clear access to necessary program resources– Customer, program, and vendor acceptance of PMAS– Jointly established success criteria

18

Program Management Accountability System (PMAS)

• All incremental development programs will be managed rigorously to schedule– A program/project will be halted on its third missed customer delivery milestone

• Once halted, substantial changes must be made before the program can restart– Need for program/project will be re-assessed– Program approach will be re-assessed– Make/buy and program design decisions will be re-assessed– Program management assignment will be revisited– Government staff assignments will be revisited– All service contracts will be re-visited– New program plan must be approved

• Flexibility can be earned

Collaboration is key to IT success.

Acquisitions•Established a dedicated acquisition office to

support OIT program planning and execution•Provide life cycle acquisition support from

program inception through completion by a multi-functional IPT

•Implementing joint Program Management Reviews to improve contract performance and program execution

•Collaboration with industry through early involvement of requirements and transparency

Acquisitions plays a dedicated and integral role in project IPTs.

Conclusions

• Investment vs. Value

• Consensus of IT “Sellers” and “Buyers” on Business Need

• Need for Incentives

• Information Interoperability

• Collaboration at all Levels Essential

• Rigorous Program Management and Acquisitions Process