LEVERAGING LEVERAGING INFORMATION SYSTEMS INFORMATION SYSTEMS TO TRANSFORM PATIENT TO TRANSFORM PATIENT

CARE ATCARE ATCentral Arkansas Veterans Central Arkansas Veterans

Healthcare SystemHealthcare System

MICHAEL WINN, MEDICAL CENTER DIRECTORMICHAEL WINN, MEDICAL CENTER DIRECTORMARGIE SCOTT MD, CHIEF OF STAFFMARGIE SCOTT MD, CHIEF OF STAFF

A flagship Department of Veterans Affairs (VA) healthcare provider, CAVHS is one of the largest and busiest VA medical centers in the country with 551 operating beds.

In FY 2010, CAVHS treated 77,136 unique patients which included:

738,245 Outpatient Visits 27,942 emergency department visits12,430 Patient Discharges

CAVHS CAVHS

Mountain Home

Hot Springs

El Dorado

CAVHS

Little Rock/North Little Rock

Mena

Medical Center

Outpatient Clinic

CAVHS provides services to our veterans through 8 Community-Based Outpatient Clinics (CBOC’s)

El Dorado ConwayHot Springs RussellvilleMenaMountain HomePine BluffSearcy

CAVHS provides a comprehensive spectrum of inpatient and outpatient healthcare services within the Little Rock and North Little Rock facilities. CBOCs offer our rural veterans the following services close to home: primary care, mental health, wellness care, social work, teleretinal imaging, laboratory, radiology, pharmacy.

Pine Bluff

Searcy

Russellville

Conway

CAVHSCAVHS

CAVHS serves as a teaching facility for more than 1600 students and residents enrolled in approximately 90 educational programs.Affiliations: University of Arkansas for Medical Sciences (includes the College of Medicine, Nursing, Pharmacy, Public Health and Health Related Professions); plus other additional educational affiliations

VISN 16

As part of VISN 16, CAVHS serves about 170,000 veterans residing throughout 46 counties in Arkansas.

• Programs– Ambulatory Care– Audiology & Speech Pathology– Complex Laboratory Services– Emergency Medical Services– Home Health Care Services– Medical Services

• Cardiology• Dermatology• Endocrinology• Gastroenterology• Hematology/Oncology• Nephrology• Pulmonary• Renal• Respiratory Care• Telemedicine

– Neurology

– Nuclear Medicine– Nutrition and Food Services– Physical Therapy– Primary Care Services– Radiology– Surgical Services

• Ambulatory Surgery• General Surgery• Thoracic Surgery• Vascular• Otolaryngology• Neurosurgery• Ophthalmology• Orthopedics• Urology• GYN• Plastic• Podiatry

Operating Beds: 195

Type of Facility: Tertiary Care

Little Rock CampusLittle Rock CampusJohn L. McClellan Memorial Veterans HospitalJohn L. McClellan Memorial Veterans Hospital

North Little Rock CampusEugene J. Towbin Healthcare CenterEugene J. Towbin Healthcare Center

Special Programs Comprehensive Homeless Program Dental Services Geriatric Services

Adult Day Health Care Community Living Center Respite Community Residential Care Senior Companions Independent Living

Alzheimer's Chronic Mentally Ill

Geriatric Research, Education and Clinical Center

Home Health Care Services

– Mental Health Services• PTSD• Special Treatment Section• Residential Rehabilitation

Treatment Program• Veterans Industries/Transitional

Residence Program• Inpatient Psychiatry• MHICM• Psychiatric Telehealth

– Physical Medicine & Rehabilitation– Primary Care Services– Prosthetic & Sensory Aids Services– Research

Operating Beds: 356

Type of Facility: Primary Care, Extended Care,

Rehabilitative Care, Mental Health Care

CAVHS DATA DRIVEN----FOR BETTER DECISIONS

WORLD CLASS INFORMATION SYSTEM

BWATP?

BWATP?

CPRS TOOLS FOR MEDICATION RECONCILIATION

• JOINT COMMISSION STANDARD• MUST OCCUR AT CHANGES IN MEDS, LEVELS OF

CARE e.g. admission, transfers and discharges• Opportunity to prevent medication errors,

improve patient education• Supplements Bar Coded Medication

Administration (BCMA) safety features

• STORM Involves physician, pharmacist and nurse

• Documentation occurs smoothly using pre-discharge order set that includes:– Meds to start, stop and

changed dosing instructions.– Automatically generated

pharmacist alert– Alphabetized list of all active

meds (Outpt, Inpt, NonVA)– List automatically loads into

Discharge Instructions– Discussed with patient by

nurse.

•EFFECTIVENESS• Clearer instructions from physician• Listing allows pharmacist to readily detect duplicate meds• Facilitated patient instruction by nurse

•EFFECTIVENESS cont’d

Med Rec Interventions By PharmacistsJune 2009-March 2010

DRUG INTERACTIONS

BWATP?

VistA Data Extracts• VistA is “real time”• All other sources are retrospective (e.g. External

Peer Review Program data is two months old)• Allows for “concurrent” monitoring• FY 2009 CAVHS struggling with a few performance

measures that were clinical reminder driven.• Reminders were enhanced and education provided• Did not always help sufficiently• Daily “automated “ reviews of Clinical Reminder

completion began first quarter FY 2010

DAILY AUTOMATED CLINICAL REMINDER

REVIEWS• VistA Clinical Reminder due report template developed for 22 reminders.

• Half nursing driven• Half provider driven• Schedule to run each morning• Patient-specific listing of missed

reminders by clinic/provider generated and sent to provider or nurse caring for that patient.

• Corrections expected• Missed reminders plummeted by 90% in

two weeks

DAILY AUTOMATED CLINICAL REMINDER REVIEWS continued

• Weekly aggregate report also automatedWeekly aggregate report also automated• Put into dashboard containing:Put into dashboard containing:

– 22 Reminders22 Reminders– By location and service, including CBOCBy location and service, including CBOC– Targets ListedTargets Listed– Color coded (Blue=100%, Green=above target, Color coded (Blue=100%, Green=above target,

Red=below target)Red=below target)– Present at 2Present at 2ndnd Morning report each Wed Morning report each Wed– Relevant service chiefs involved in action plans Relevant service chiefs involved in action plans – Available to all staff, including CBOCs, via Web siteAvailable to all staff, including CBOCs, via Web site

EXAMPLE OF WEEKLY DASHBOARD

REMINDER TARGETPCC LR

WOMEN'SPCC NLR

PINE BLUF

F

MT HOME

HT SPGS

MENAEL

DORSEARCY GERI CARD

DM ENDO

PULMMNT HLTH

TOTAL

TOBACCO SCREENING 93% 94% 95% 95% 94% 98% 100% 98% 94% 97% 100% 90% 92% 91% 93% 93%

PTSD SCREENING 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 96% 94% 98% 98% 99%

DEPRESSION SCREENING

95% 96% 96% 100% 100% 100% 97% 100% 95% 100% 100% 84% 82% 82% 95% 95%

ALCOHOL USE SCREENING (AUDIT-C)

95% 97% 98% 97% 98% 100% 99% 100% 97% 100% 100% 82% 84% 88% 97% 96%

L-MOVE Weight Screening

90% 95% 92% 93% 100% 96% 98% 100% 94% 97% NA 80% 81% 84% 93% 94%

PNEUMOCOCCAL VACCINE

94% 99% 100% 100% 100% 100% 100% 98% 96% 100% 100% 97% 100% 100% 94% 98%

FOBT SCREENING 79% 97% 96% 97% 100% 98% 93% 98% 98% 100% 100% 86% 89% 90% 87% 93%

IRAQ & AFGHAN POST-DEPLOYMENT

97% 99% 100% NA 100% NA NA NA 100% < 6 cases NA < 6 cases < 6 cases 100% 97% 97%

TBI SCREENING 95% 100% 100% NA 100% NA NA NA 100% < 6 cases NA < 6 cases < 6 cases 100% 98% 99%

Evaluation of + PTSD Screen

77% 95% 100% 100% 100% 100% 100% 92% 94% 100% NA 86% 100% 100% 98% 97%

Evaluation of + Depression Screen

77% 95% 100% NA 100% 86% 100% 100% 100% 93% NA 82% 100% 79% 95% 94%

Evaluation of Positive AUDIT-C

62% 88% 100% NA 83% NA NA NA NA NA NA 100% NA 80% 89% 88%

PAP Smear Screening 90% 93% 100% NA NA NA NA NA NA NA NA NA NA NA 82% 81%

Mammogram Screening 77% 88% 100% NA NA NA NA NA NA NA NA 100% 89% NA 93% 92%

Colorectal Cancer Screen

79% 93% 90% 88% 97% 90% 88% 88% 95% 96% 97% 86% 89% 91% 86% 89%

Ischemic Heart Disease Lipid Profile

95% 96% 97% 80% 97% 94% 91% 96% 95% 95% 87% 90% 96% 89% 93% 94%

Diabetic Eye Exam 88% 92% 90% 100% 89% 100% 94% 96% 96% 100% 96% 91% 95% 93% 87% 91%

Diabetic Foot Eval 75% 82% 85% 75% 94% 95% 94% 88% 96% 100% 89% 66% 95% 82% 73% 81%

VESTED 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 99% 100%

PSA 90% 94% NA 96% 99% 100% 97% 93% 91% 73% 82% 88% 86% 88%

GRAND TOTAL 90% 85% 94% 96% 93% 95% 93% 94% 93% 82% 85% 83% 84% 87%

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OCT 11-15, 2010CLINICAL REMINDER COMPLETION RATE

NA100% ABOVE TARGET BELOW TARGET N < 5

RESULTSFour Examples

RESULTSOne More Example

BWATP?

USING VSSC DATA• Excellent source of workload,

performance measure, cost and other types of data

• Updated every two weeks• Primary source is VistA• Data available for each VA

Medical Center, clinic, CLC, etc.

• Useful for management, performance improvement and strategic planning

TRACKING IMPACT OF CBOCSVSSC MARKET SHARE DATA

BWATP?

DATA WAREHOUSING

• VISN 16 developed first data warehouse in VHA

• Used CAVHS IT staff• Housed at CAVHS• Advanced SQL Relational Database

(relatively easy to learn by Non IT staff)• Biweekly extract of VistA (e.g.

outpatient visits, discharges, procedures, prescriptions, ancillary tests, diag codes, costs)

• Provider Dashboards developed in 2005

PROVIDER DASHBOARDS• Individual dashboards for

70 physicians and APNs in Primary Care, Geriatrics, and Endocrinology

• Generated, distributed monthly

• Used to guide performance improvement and also performance awards

PROVIDER DASHBOARDEXAMPLE

PROVIDER DASHBOARDS continued

• Dashboards generated that aggregate performance results up to:– Each CBOC– Each division (Little Rock

and North Little Rock)– Healthcare System

(entire organization)

PROVIDER DASHBOARDS

continued

Example of a CBOC

Level Tracking

PROVIDER DASHBOARDS Impact of Dashboards

DATA WAREHOUSING

continued• Example of special study• Analysis of colonoscopy

and biopsy results for patients:– With Positive FOBT

leading to diagnostic colonoscopy

– Screening colonoscopy by age and risk factors

COLONOSCOPY STUDY continued

• Data Warehouse environment facilitated complex analysis of multiple fields across several VistA packages– Clinical Laboratory (FOBT results)– Procedures (colonoscopy performed)– Tumor Registry (cancer staging)– Anatomical Pathology (tissue analysis, dysplasia or cancer

present)• Skills can be developed by non-IT staff• VistA programming for similar analysis requires strong “M”

programmer, limited to a few IT staff.

CATEGORYTOTAL

SCOPED

# CANCER

DX

% CANCER

DX

# ADENOMA

% ADENOMA

# DYSPLASIA

% DYSPLASIA

# OTHER (no CA,

Adenoma or Dysplasia)

% OTHER (no CA,

Adenoma or Dysplasis)

CASES WITH POSITIVE FOBT FOLLOWED UP WITH COLONSCOPY

499 14 2.81% 133 26.65% 2 0.40% 350 70.14%

CASES WITH COLONSCOPY NOT

PRECEEDED BY POSITIVE FOBT

1738 23 1.32% 394 22.67% 1 0.06% 1320 75.95%

TOTAL CASES WITH COLONOSCOPY

2237 37 1.65% 527 23.56% 3 0.13% 1670 74.65%

COLONOSCOPIES BETWEEN OCT 1, 2009 AND AUG 6, 2010ALL PERCENTAGES ARE BASED ON TOTAL SCOPED AS DENOMINATOR

CATEGORYTOTAL

SCOPED# CANCER DX % CANCER DX

# ADENOMA/ DYSPLASIA

% ADENOMA/ DYSPLASIA

# OTHER (no CA, Adenoma or

Dysplasia)

% OTHER (no CA, Adenoma or

Dysplasis)

CASES WITH POSITIVE FOBT FOLLOWED UP WITH COLONSCOPY

499 14 2.81% 135 27.05% 350 70.14%

CASES WITH COLONSCOPY NOT

PRECEEDED BY POSITIVE FOBT

1738 23 1.32% 395 22.73% 1320 75.95%

TOTAL CASES WITH COLONOSCOPY

2237 37 1.65% 530 23.69% 1670 74.65%

COLONOSCOPIES BETWEEN OCT 1, 2009 AND AUG 6, 2010ALL PERCENTAGES ARE BASED ON TOTAL SCOPED AS DENOMINATOR

FY10 DUSHOM SYSTEMS REDESIGNFee Services Initiative

FY10 CAVHS Systems RedesignOR 1st Case Start Time Initiative

CODE FLASH STARTED

RAPID RESPONSE TEAM• Early adopter of this patient safety initiative• Best practice according to VISN 16

BWATP?

LEVERAGING INFORMATION SYSTEM TECHNOLOGY FOR BUSINESS PLANNING

• CAVHS WEB ENTRY OF BUSINESS PLANS

• “BEST PRACTICE” - 2010 CAREY SITE VISIT TEAM

• CREATES INDIVIDUAL SERVICE BUSINESS PLANS FOR BUSINESS PLAN HEARINGS

• CREATES DATABASES FOR SWOC ANALYSIS, FTEE REQUESTS, FUND CONTROL POINT REQUESTS, EQUIPMENT NEEDS, PLANNING ACTIONS, ETC.

BUSINESS PLAN

HOMEPAGE

BUSINESS PLAN TRAININGSERVICES GIVEN GUIDANCE FOR COMPREHENSIVE

JUSTIFICATION FOR RESOURCES

LISTENING TO OUR EMPLOYEESLISTENING TO OUR EMPLOYEESIMPLEMENTATION OF UNIT SHARED GOVERNANCEIMPLEMENTATION OF UNIT SHARED GOVERNANCE

LEVERAGING SATISFACTION DATALEVERAGING SATISFACTION DATA

ALL HAZARDS EMERGENCY PREPAREDNESS TRAINING2000-2010

DISCUSSIONDISCUSSION