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VeHU 143
I’ll share if you share:
VA DoD Clinical Information
W. Paul Nichol, MD
National Director Medical Informatics
Patient Care Services
Dick Rickard. PMP
Project Manager CHDR & RDI
Greg Donham, MS
Interagency Program Manager
BHIE/FHIE Program Office
Session Overview
Evolution
VA/DoD Joint Electronic Health Records Interoperability
Plan - Overarching Strategy
The Path to Interoperability
Federal Health Information Exchange (FHIE)
Bidirectional Health Information Exchange (BHIE)
Pre and Post Deployment Health Assessment Data
Clinical /Health Data Repository
Other Ongoing Integration Efforts
2
Local VA DoD Sharing
Team Puget Sound
NDAA IT Sharing Demonstration Project
VAPSHCS American Lake Campus Madigan Army Medical Center
3
Evolution of VA DoD Data Sharing
Phone/Fax/Paper
Local EMR Enhancements/ copy-paste/ scan
Remote log on
VPN/ SSL to CPRS
SSL to ICBD/HealtheForces
Record Flags – Active Inpatient/ DoD Treatment
CPRS Patient List
Progress Note
Discharge Summary – copy/paste to CPRS
4
VA/DoD Joint Electronic Health Records
Interoperability Plan –
Overarching Strategy
5
VA/DoD Electronic Health Record
Joint Electronic Health Records Interoperability (JEHRI) Plan
Developed collaboratively by VA & DoD
Approved by the VA/DoD Joint Executive Council (JEC)
and signed by the VA Under Secretary for Health (USH)
and DoD Assistant Secretary of Defense, Health Affairs
(ASD(HA))
Approved by OMB
Provides the roadmap to achieve VA/DoD interoperability
Two Phases
Phase I – One way electronic data exchange
Phase II – Bidirectional and computable data exchange
6
VA/DoD Electronic Health Record
JEHRI Goals:
Improve sharing of clinically relevant information
Adopt common standards for architecture, security,
communications, data, technology and software
Seek joint procurements and/or building of applications
Seek opportunities for sharing existing systems and
technology
Explore convergence of VA and DoD health information
technology applications where feasible and within mission
requirements
Develop interoperable health records and data repositories
7
The Path to VA/DoD Interoperability
8
DoD/VA Interoperability Initiatives
DoD VA
One-way, enterprise
FHIE exchange of text data FHIE
Bidirectional real-time
BHIE exchange of text data BHIE
Bidirectional real-time
CHDR enterprise exchange of
computable data
CHDR
9
Federal Health Information Exchange (FHIE)
Information Sharing in Operation
10
Federal Health Information Exchange (FHIE)
Successfully completes Phase I of JEHRI – operational at all VA medical centers
since 2002---Fifth Anniversary on Memorial Day !
One-way transmission of electronic military health data from DoD’s legacy health
information system, CHCS, to VA’s VistA Computerized Patient Record System
(CPRS) – the point of care
Averages over 17,000 uses of FHIE/BHIE data each week (compared to 8,200
last year)*
DoD has transmitted data to the FHIE repository on approximately 3.7M
unique patients*
VA has provided care or treatment or benefits to over half of the unique DoD
patients using FHIE data *
Permits VHA clinicians and VBA disability claims processors to view historical DoD
data: Patient Demographics for Identity Management, Laboratory results,
Radiology reports, Outpatient Government and Retail Pharmacy data, Allergy data,
Admission, Disposition and Transfer (ADT) data, Consultation Reports, Discharge
Summaries, and outpatient coding from DoD’s Standard Ambulatory Data Record
Intergovernmental Solutions Finalist, 2005
*As of 9 May 2007 11
Pre & Post Deployment Health Assessments
Re-used FHIE architecture to support the ability of VA clinicians and VBA
examiners to view with CPRS historical pre- and post-deployment health
assessment (PPDHA) data on separated Service members. These data are
collected prior to and immediately following deployments by Service Members,
Reserve and National Guard members and include:
Patient Identity
Deployment locations
Immunizations
Hazardous exposures
Physical and mental health assessments
Operational in VA since December 2005
DoD has transmitted over 1.7M PPDHA on more than 700,000
individuals who are separated Service members and Reserve and
National Guard Members who have been deployed and are now
demobilized*
DoD continues to send monthly updates provided to VA containing data
on separating Service members and demobilized Reserve and National
Guard Members
Operational in VA since December 2006, DoD Post Deployment Health
Reassessment data is available from DoD through weekly transmissions for
follow-up care in VA 12
*As of May 2007
CHCS-VistA
Bidirectional Health Information Exchange
(BHIE)
Bridging the Gap
13
BHIE Interoperability Goals
To provide the best healthcare possible to
the U.S. Military and our Veterans
Operate a joint system for transfer of
electronic health information between DoD
and VA that contributes to veterans’ health
Provide on-demand electronic health
information to assist in the compensation
process
Ensure compliance with HIPAA regulations
and security requirements with existing
systems
Create an environment for storing very
sensitive information
Use a patient-focused information technology
familiar to authorized VA and DoD users
14
Bidirectional Health Information Exchange (BHIE)
BHIE brings real-time, bidirectional exchange of current medical information
reusing FHIE infrastructure between CHCS and VistA CPRS – current health
information systems
BHIE supports the care of shared patients at joint sites, including dependents
Bidirectional transmittal and display of:
Patient Identification Management
Outpatient pharmacy information
Allergy data
Laboratory result data, including microbiology and pathology reports
Radiology text reports
Discharge Summaries*
Initial VA implementation in October 2004 and now operational at all VA sites
and select DoD sites worldwide
Currently exploring increasing domains of data available through BHIE
Recipient of the Excellence.gov Award in 2006 15
High-Level FHIE/BHIE Architecture
FHIE/BHIE
DoD Framework VA
MHS
DMSS Data Repository
FHIE
HL7 Repository
PDTS
SADR CPRS
CHCS CHCS
K61
CHCS
Sharing Pre/Post
Facility Query
Access
FHIE/BHIE VistALink VistA
CACHE’ VA Host
Framework RDV
HL7/ADT (Station 200) VistA
WS/XML Local
VAMC
DoD HL7/ADT
CIS
Web Server
PIDS/ Correlation
Vitria
WS/XML IE VA
MPI
-Patient ID Management
-Information Locator
DoD GUI
-Security
-Optimization
-Adapter/Connector
16
BHIE Sites: Current and Pending
NACC Groton
Bassett ACH
Madigan AMC Minot AFB
Walter Reed AMC
NCA
Evans ACH Malcolm Grow MC
NHC Great Lakes
Wright-Patterson AFB Dewitt ACH
David Grant MC NMC Portsmouth
Irwin ACH
NH Lemoore Leonard Wood ACH Womack AMC
Mike O’Callaghan Federal Hospital Eisenhower AMC
Elmendorf AFB
NH Camp Pendleton Fox AHC NH Camp Lejeune
NMC San Diego Kirtland AFB
NHC Charleston
Martin ACH
William Beaumont AMC
NH Jacksonville
NH Pensacola
Tripler AMC
Darnall AMC
MacDill AFB
Brooke AMC NH Corpus Christi
Wilford Hall
LRMC
BHIE operational BHIE-CIS operational
BHIE implementations planned during FY2007
28 DoD host sites = 15 DoD Medical Centers, 20 DoD Hospitals & over 200 DoD Clinics
10 CIS Sites
(Access to over 2.2 Million correlated patients)
17
BHIE Data Access
DoD Military FHIE
All VA
Treatment Facilities Repository
Facilities
with BHIE
Records
Returned
Requests
for Records
Authorized
Inquiry
Index of where
patients have records Temporary aggregate
clinical record
FHIE Framework
VA Facility
or DoD Facility
Patient data
delivered to
Physician
18
FHIE/BHIE - Remote Data Viewing
Data types now available
Outpatient medications
Allergies
Lab – Chemistry, Hematology, Micro, Path, etc
Radiology Text Reports
Pre and Post Deployment Assessments
Post Deployment Health Re-Assessment
Discharge Summaries* (10 VA DoD Essentris Sites)
Data types in the works
Patient identifiers for OEF/OIF, TBI, Polytrauma
Priority being given to data to support returning veterans
Progress notes and consultation reports
Inpatient medications
Problem list
Imaging
19
BHIE - Remote Data Viewing
VA
CPRS Remote Data Views
VistA Web
CPRS-R*
DoD
SHARE
AHLTA*
20
Screen Shots – CPRS
21
Screen Shots – CPRS
22
Screen Shots – CPRS
23
Screen Caps - VistaWeb
24
Screen Caps - VistaWeb
25
Screen Caps - VistaWeb
26
Screen Shots – SHARE
27
Screen Shots – SHARE
28
Screen Shots – SHARE
29
NDAA VA DoD IT Sharing Demonstration Project
FHIE->BHIE->C/HDR
National Defense Authorization Act (NDAA) in FY 2003
funded 3 VA DoD IT Sharing Demonstration Projects
Team Puget Sound (MAMC+VAPSHCS) Project
components
Data Exchange
Implementation Guides – HL7 CDA
User Interface Requirements
Other NDAA Projects
Reference lab data exchange
Credentialing and privileging
30
Project Goals/Objectives
The objective of the Team Puget Sound
(TPS) National Defense Authorization Act
(NDAA) Demonstration Project is to
develop the requirements and capabilities
to ensure that relevant patient information
is readily accessible electronically to
clinicians at both VA and DoD sites and
displayed in a clinical useful manner.
31
Limitations
Some limitations of current status:
Incomplete document types
Limited encounter/ billing data
Incomplete medications (no inpatient meds/OTC)
No problem list
No provider contact information
No advance directive information
Clinical reminders do not cross systems
Limited functionality of user interface
Inability to graph
No worksheet view
Limited ability to customize, manipulate views
Not context sensitive
No decision support
32
Major Accomplishments
Technical Documentation (TD)
Completed CDA R1 Implementation Guide - Oct 05
Completed CDA R2 Implementation Guide – May 06
Completed OV, SV, TV – Nov 06
33
CDA R1 Implementation Guide
Completed in October 2005.
Used in TPS Cycle 1 as a container
for unstructured text body.
34
CDA R2 Implementation Guide
Completed in May 2006.
Used in TPS Cycle 2 and 3.
Based on Care Record Summary (CRS)
Implementation Guide.
Written with other MHS and VA implementations in
mind.
Will be used in Essentris to BHIE interface for
MAMC inpatient notes.
By keeping to the CDA standard, interfaces with
other partners will be easier.
Used as an example for other CDA R2
implementation guides written by MHS and HL7
organizations.
35
CDA R2 Example
Discharge Summary in CDA
HEADER (not a complete example)
<?xml version='1.0' encoding='UTF-8'?>
<?xml-stylesheet type='text/xsl' href='IMPL_CDAR2.xsl'?>
<ClinicalDocument xmlns='urn:hl7-org:v3' xmlns:crs='urn:hl7-org:crs' xmlns:xsi='http://www.w3.org/2001/XMLSchema-
instance'>
<id extension='12345_200603231855' root='2.16.840.1.113883.3.42.2.0125'/>
<code code='34133-9' displayName='SUMMARIZATION OF EPISODE NOTE'
codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
<title>MADIGAN ARMY MEDICAL CENTER DISCHARGE SUMMARY</title>
<effectiveTime value='20060323185504+0500'/>
<recordTarget>
<patientRole>
<id extension='20111223333' root='2.16.840.1.113883.3.42.3.0125'/>
<addr>
<streetAddressLine>.</streetAddressLine>
<city>Anywhere</city>
<state>XX</state>
<postalCode>00000</postalCode>
<country>USA</country>
</addr>
<telecom value='tel:(000)000-0000' use='HP'/>
<patient>
<name>
<prefix>Mr.</prefix>
<given>VA DoD</given>
<family>Patient One</family>
</name>
. . . . . . . . . . 36
CDA R2 Example
Discharge Summary in CDA
Structured Body (L2) (not a complete example)
<component>
<structuredBody>
<component>
<section>
<code code='11535-2' codeSystem='2.16.840.1.113883.6.1'
displayName='HOSPITAL DISCHARGE DX'/>
<title> Conditions </title>
<text> Severe COPD w/ exacerbation on 5L as an outpt, PFTs
mmm YY: DLCO 2.33, TLC 5.3, Vc 2.9, Frc 3.33, RV
2.4; Pre-bronchodilator: FVC 2.39, FEV1 1.16,
FEV1/FVC 46%; Post-bronchodilator: FVC 2.54, FEV1
1.16, FEV1/FVC 46%; Severe obstruction w/ no
post-bronchodilator response. </text>
</section>
</component>
<component>
<section>
<code code='10155-0' codeSystem='2.16.840.1.113883.6.1'
displayName='HISTORY OF ALLERGIES' />
<title> Allergies </title>
<text> . . . . </text>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument> 37
Major Accomplishments
Information Exchange Technology (IET)
Completed BHIE Phase 1 (Bidirectional)
Patient Identification
Allergies
Prescriptions
Completed BHIE Phase 2 (Bidirectional)
Laboratory Results
Radiology (reports)
Completed TPS Cycle 1 (DoD to VA)
Inpatient Discharge Summaries via GDNii using CDA R1
Completed IDS – CLIN 1 / BHIE Phase 3 (Bidirectional)
Inpatient Discharge Summaries from Essentris and VistA
Completed TPS Cycle 2 (DoD to VA)
Historical outpatient notes from GDNii using CDA R2 format
In progress – Migration of IDS – CLIN 1 to CDA R2 format
38
TPS User Interface Requirements Methods
Interviews
Surveys
Structured questions
Heuristc evaluation
Uses cases/ stories
User personae
Scenario based diagnostic usability tests
39
VA DoD Data Sources for Sharing
40
TPS IT Sharing Identified Data Needs
41
Alternate Interfaces
42
TPS NDAA VA DoD IT Sharing Demo
43
Lessons Learned
Significant differences exist between VA and
DoD
Information systems
Policies and practice
Workflow/ business practice
Terminology/expectations
Many end-user requirements for use of remote
data are similar between VA and DoD; between
VA’s, and between VA and private or affiliated
health care systems
44
Lessons Learned
Discharge “Summary” Example
Seven different discharge documents, including
summary, note, and ER discharge note
DC Summary contains billing information with ICD
and CPT codes but not narrative
Multi-disciplinary discharge note looks most like VA
DC Summary but:
Not authenticated by signature of responsible
physician
Remains editable by members of the care team
Resident determines complexity of care and
need for formal dictated summary
45
46
47
48
Lessons Learned
Direct patient care benefits will increase as
users gain familiarity/experience and
capabilities expand
Continuity
Improved case management capabilities
Safety
Medication reconciliation
Efficiency
Reduced redundancy
Timesaving in clinical process flow
Timeliness
49
Lessons Learned
Best access to remote data is integrated into
local EMR, or at least context linked
Maintenance of multiple accounts not viable solution
Security and firewall issues are complex
Communication across systems is critical
Verify assumptions and direction regularly
Downtime issues
Differences in ability to handle different
document types needs to be addressed
There is room for significant improvement in the
user interface – opportunity for joint
development
50
LessonsLearned – HIMS View
Differing document definitions
Discharge summary vs Multi-disciplinary discharge note
Version control
Handling amended/corrected records
Best if records are maintained by parent facility and accessed when
needed, rather than keeping a local copy
Record signing/authentication policies differ and need to be understood
Care is documented in system where patient is seen, even care provided by VA
staff at DoD facility
Potential for more extensive access to data across VA and DoD systems than
veterans may be aware of at present
Differences in coding may exist but don’t impact current reimbursement
mechanisms between VA and DoD
51
Lessons Learned
Positive Aspects of VA DoD Environment
Common patient identifiers, correlation
framework, and secure exchange environment
(through BHIE) is a huge advantage
Sharing agreements in place in many locations
Information exchange covered by Privacy Act
“Routine Uses” 43 and 47
Common mission and patient population
Local and enterprise staff with extensive
experience in electronic medical records
52
Summary
Data exchange capabilities are rapidly
expanding between VA and DoD
Computable data will be increasingly available
to support activities like order checks (RDI) and
decision support
Standards/Standardization and improved user
interfaces are needed to optimize systems
It will be a challenge to keep clinical practice
patterns, workflow, and policies up to date with
technologic capabilities – but well worth the
effort
53
Summary of CHDR/BHIE/FHIE Features
Real
Project Mediated Computable Time Bidirectional Storage Deployed DoD Participation
CHDR Yes Yes Yes Yes Yes Sept 06 All sites with AHLTA and the
CDR installed will
participate. Data for all ADC
patients will be shared.
BHIE No Partial Yes Yes No Oct 04 All VA/DoD Sharing
Locations will participate.
Data for all patients seen in
both DoD and VA will be
shared.
FHIE No Partial No No Yes May 02 All CHCSI sites will
participate. Pre-separation
data will be shared after
separation.
BHIE and FHIE have a larger number of available reports such as
Radiology, Lab, and Pre/Post Deployment Assessments.
CHDR allergy and pharmacy data will be used in drug/drug and
drug/allergy interaction alerts
54
The Clinical Data Repository / Health Data
Repository (CHDR)
The Interoperable Health Record
55
Where CHDR Fits
Supports interoperability between DoD’s
Clinical Data Repository (CDR) &
VA’s Health Data Repository (HDR)
Two-way, enterprise exchange
of computable data between
next-generation systems 56
CHDR Overview
What CHDR does
Enables the VA's HDR and the DoD's CDR to exchange
computable data
CHDR Functions
Establish ADC: Standalone application to “mark” patients having
dual care eligibility as “Active Dual Consumers”
Data Exchange & Flow: An initial exchange of data at “marking”,
and subsequent flow whenever one side or the other has new data
to share
How it does it and how it is used
Standardization & Mediation: Uses an agreed terminology standard
as a translator into each agency’s native vocabulary
Persisted: Data from DoD becomes part of the VA patient's medical
record and vice versa
Query: RDV & VistAWeb (DoD’s AHLTA)
Decision Support: RDI (DoD’s PDTS) real time drug-drug and drug-
drug allergy alerts 57
CHDR Program Structure
Program and Project Management
Mirrored within each agency
Interagency Program Support Office with manager and
shared contract support staff providing
Liaison for interagency communications and issue management
Oversight of Interagency Project Management Plan
Oversight of agency internal and interagency dependencies
Facilitation of standardization and mediation
Autonomy and Interdependence
Common requirements, products and timelines
Independent management of agency issues and responsibilities
Independent culture and processes (e.g. Field Test, Release)
Agencies determine their own mechanisms for processing data in
their respective applications 58
Domain Sequencing
Initial Domains: Outpatient pharmacy and drug allergy
Began exchanging data for Active Dual Consumers June 2006
Field Test complete at seven VA-DoD joint venture sites
El Paso VA HCS and Wm Beaumont AMC
Augusta VAMC and Eisenhower AMC
VA Gulf Coast HCS (Pensacola) and NH Pensacola
VA Puget Sound HCS and Madigan AMC
N. Chicago VAMC and NH Great Lakes
VA San Diego HCS and NMC San Diego
VA Southern Nevada HCS (Las Vegas) and Mike
O’Callaghan Fed Hospital
National deployment scheduled for this year
Next Domain: Laboratory data (chemistry and hematology)
Future Domains: Under consideration
59
Order Checks
Original
VA
Local VistA
Local Order Checks
60
Order Checks (cont.)
With RDI
VA
Local VistA
Agency Order Checks
HDR
61
Order Checks (cont.)
VistA, VistAWeb, With RDI & CHDR AHLTA, PDTS
CHDR, etc.
VA DoD
Local VistA
Interagency Order Checks
HDR CHDR CHDR
Services Services CDR
VA Master Patient
Patient Index Index
STS TSB
(Mediation) (Mediation)
ADC File
62
VistAWeb – CHDR (DoD) OP Pharmacy
63
VistAWeb – CHDR (DoD) Allergy
“ ” Suffix
*
64
CPRS Drug-Drug Order Check
VA clinician writes a new order.
65
CPRS Drug-Drug Order Check
CPRS order check warns of a significant drug-drug
interaction with the existing DoD (4th Medical
Group) prescription.
66
CPRS Drug-Allergy Order Check
CPRS– Patient has an existing allergy received from DoD
via CHDR & stored in the HDR.
67
CPRS Drug-Allergy Order Check
The VA clinician writes new order.
68
CPRS Drug-Allergy Order Check
Order checking warns of a significant drug-allergy
interaction between the DoD allergy for
HYDROCHLOROTHIAZIDE and the attempted VA
prescription for HYDROCHLOROTHIAZIDE.
Remote allergy source is not available in CPRS.
69
Implementation Status
• National Deployment strategy
– “Manual”, controlled implementations
– RDI: First decision support tool
– CHDR: Site sharing relationships (DoD)
• RDI Project
– Product released in June 2007
– Deployment update
• CHDR Project
– Product release date
– Deployment plans
70
Lessons Learned
• Things to be aware of
– Centralized architecture
• Different way of thinking
– Field Test Data (since June 2006)
• Many sites have already been seeing DoD data
– Duplication between computable and non-
computable data (query functions)
– DoD terms that fail mediation are not included
in VA order checks or the VA record
71
Other Ongoing Integration Efforts
Laboratory Data Sharing and Interoperability (LDSI): Supports the electronic
ordering and results retrieval of chemistry laboratory tests between DoD and
VA facilities
Enterprise Architecture: Joint VA/DoD Shared Health Architecture
Plan/Charter completed a “Shared Health Architecture,” version 1.0 in
December 2004
Scheduling Interoperability: Chartered work group exploring the feasibility of
creating interoperable scheduling applications
e-Health collaboration: VA/DoD shared objectives for cooperation between
TRICARE Online and My HealtheVet
72
New Initiatives
• Veterans Tracking Application (VTA)
• Traumatic Brain Injury (TBI)
• Theater Medical Data Store (TMDS)
• Polytrauma Patient Marker
• OEF/OIF Patient Marker
• Clinical Transfer or Electronic Patient Hand-off
• DoD CPRS Paper Record Scanning Interface
• Polytrauma Imaging
• Joint Inpatient Health Record Study
• Nationwide Health Information Organization (NHIO) OR
VHIE
• Multiple initiatives in the VBA arena
73
Q&A
• Questions?
74
FOR FURTHER INFORMATION
W. Paul Nichol, MD, National Director Medical Informatics,
Patient Care Services, Paul.Nichol@va.gov
Greg W. Donham, MS, Interagency Program Manager, BHIE/FHIE
Program Office, Greg.Donham2@va.gov
Jack Mandel, Program Manager, CHDR Program Office,
Jack.Mandel@va.gov
Dick Rickard, PMP, Project Manager, CHDR & RDI
Dick.Rickard@va.gov
75
Back up slides
76
Services Standard Interfaces
Client Access
IIOP/ IIOP/
Connectors HTTPS HTTP
CORBA CORBA
PIDS SOAP/ COAS HL7 V3
Adapters
Adapter XML Adapter (Future)
Person Identification
Information Location/Collection
FHIE/BHIE Security and Privacy
Framework Services Terminology
Data Normalization (RIM)
PIDS HL7 V2.2 SQL WS
Adapter Adapter Adapter Beans
Electronic
CHSC SOAP/ Health
MPI IIOP ODBC Record Work
ftp XML
Station
EI/DS
HL7 FHIE
Repository
77
CPRS Drug-Allergy Order Check
Order checking warns of a significant drug-allergy
interaction between the DoD allergy for
HYDROCHLOROTHIAZIDE and the attempted VA
prescription for HYDROCHLOROTHIAZIDE.
Remote allergy source is not available in CPRS.
78
Acronym List
• BHIE – Bidirectional Health Information Exchange
• CDA – Clinical Documentation Architecture (national standard for information transfer)
• CHCS – Clinical Health Composite System (DoD legacy system that houses order entry and
labs, radiology reports, allergies, and medications
• DoD – Department of Defense
• EMR - Electronic Medical Record
• ICDB – Integrated Clinical Data Base (MAMC legacy documentation system)
• IET - Information Exchange Technology
• MAMC – Madigan Army Medical Center
• NDAA – National Defense Authorization Act
• SHARE – Secure Healthcare Alliance Record Exchange (web based repository of CHCS
and Essentris data to be used as portal that BHIE retrieves information from to send to VA
system)
• TPS – Team Puget Sound (Madigan AMC and Seattle / American Lake VA
development team)
• UIR - User-Interface Requirements
• VA – Veterans Affairs
• VistA – VA primary documentation system
79
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