Big Data and VistA Evolution, Theresa A. Cullen, MD, MS

Big Data and VistA Evolution
Presentation to Open Source Electronic Health Record Alliance
(OSEHRA) Architecture Work Group
Theresa A. Cullen, MD, MS
Chief Medical Information Officer
Director, Health Informatics
Office of Informatics and Analytics
Veterans Health Administration
Department of Veterans Affairs

VETERANS HEALTH ADMINISTRATION
Agenda
• Overview of the Department of Veterans Affairs (VA)
• Big Data
• VistA Evolution
2

.
3
Patient
. . . .
Patient and ProviderPatient, Provider, and Patient FamilyCommunityPopulation

Overview of VA
4

Hospital System to Health System
In 1996, VA began the creation of Veterans Integrated
Service Networks (VISNs) to transform VA Health Care
from a “Hospital System” to a “Health System.”
Veterans Health Administration (VHA) currently has 21
VISNs.
•134 Community Living Centers
•300 Vet Centers
•152 Medical Centers
•990 Outpatient Clinics
821 Community-Based
152 Hospital-Based
11 Mobile
6 Independent
•102 Domiciliary Residential
Rehabilitation Programs
Source: FY 2012 End-of-Year Pocket Card
•70 Mobile Vet Centers
5

VA’s Health Care Delivery Model
• Personalized, Proactive and Patient-Driven
• Team Care
• Continuous Improvement
• Data-Driven, Evidence-Based
• Value
• Prevention / Population Health
 Coordinated Care
6

Big Data
7

Collect and Blend the Big Data
8

Broad range of
clinical
programs
designed to
improve care for
Veterans with
complex
chronic illness
Home-based
primary care
Case-
management
Specialty
clinics, e.g.,
heart failure
Telehealth
Palliative care
• Providers can’t accurately predict
Veterans at highest risk of
deterioration
• Patient Aligned Care Team Registered
Nurse (RN) Care Managers charged to
coordinate care
• No systematic way to identify
Veterans who might benefit most 
predictive analytics using data from
Electronic Health Record (EHR)
Secondary Data Use: Research and
Predictive Analytics Capabilities
9

What’s Wrong: Data-Domain Centric
• Building blocks of EHR are data domains
– Meds, Labs, Rad, Notes, Diagnoses, etc.
• Results in bad thought-flow and workflow
10

Moving From What’s Wrong
11
Data Silos
Data
Juxtaposition
Data + Workflow
Integration

Implications of Conceptual Approach
• Goal - construct user-interface components to
facilitate clinical reasoning and work
• Address basic cognitive needs – then reuse or
reconfigure for most health care processes
• Avoid “an app for that,” while allowing for
extensibility
12

Standard Orders
13

Developing Context-Sensitive Orders
• 30 million records – 20 years of data mined to identify
relationships between
– Problems
– Laboratory results
– Prescriptions
– Procedures
– Orders
– Location
– Provider
– Patient
• 15,000 conditions and 10,000 orders
14

Common Test and Drug Orders
• Epigastric pain
– CBC with diff
– Chemistry panel
– Helicobacter pylori
– Lipase
– Amylase
– Upper GI endoscopy
– Abdominal ultrasound
– CT abdomen w/o contrast
• Omeprazole
• Ranitidine
• Amphogel
• Rabeprazole
• Promethazine
• Sucralfate
• Metronidazole
• Metoclopramide
• Docusate
15

Characteristics of VHA Analytic
Approach
• Treat corporate data as strategic resource, available
to entire organization
• Maximize understanding of organizational processes
and outcomes to promote learning and improvement
• Invest in relevant, role-based training in analytics so
tools are available widely and not just to a few
16

• For clinicians
– Real-time, structured data collection
– Population and panel management tools
• For leadership
– Understanding organizational performance and
vulnerabilities
• For public/consumers
– Unparalleled transparency and public reporting
Products
17

Care Assessment Need (CAN) Report
• CAN provides estimated
probability of death/hospital
admission w/in specified time
frame (90d or 1 yr)
• Score expressed as a percentile 0-
99; higher score indicate follow-
up assessment
• Provides patient level detail
• Accessible through VHA Support
Service Center (VSSC) website
and Computerized Patient Record
(CPRS) tools menu
• For primary care providers,
and/or nurse care manager
• Model developed in collaboration
with VA researchers and policy
leaders
18

VHA’s Analytic Journey –
Summary Themes
• Leverage and integrate information (break down silos) to gain
insight and efficiency
• Collaborate across multiple data sources and agencies (e.g.,
Veterans Benefits Administration, Department of Housing and
Urban Development (HUD), Department of Health and Human
Services (HHS))
• Move from retrospective performance reports to real-time
prediction, decision support, and practice support
• Enhance analytic skills throughout Veterans Health
Administration (VHA) workforce
• Promote transparency and accountability
19

VistA Evolution
20

Background
• In 2013, VA and Department of Defense (DoD) Secretaries
made decisions that require a change in EHR strategy
• The VA EHR core will be VistA-based
• Our mission has not changed
21
“to care for him who shall have
borne the battle, and for his
widow, and his orphan”

VETERANS HEALTH ADMINISTRATION ‘Conceptual’ representation of current
EHR/Health Information Technology Landscape
VistA
Standardization
VistA
CPRSiEHR
HMP
Janus
JLV
VLER Health
VistA
Web
RDVs
Connected
Health
Current VA Landscape
22
Over the past several
years, various
products have been
developed across the
VA landscape,
creating a complex
suite of applications
CAPRI
Acronyms:
CAPRI – Compensation and Pension
Record Interchange
HMP – Health Management Platform
iEHR – integrated Electronic Health
Record
JLV – Joint Legacy Viewer
RDV – Remote Data Views

Roadmap
2014 2015 2016 2017
Initial
Operating
Capability
(IOC)
Office of the
National
Coordinator
(ONC)
Certification
2014 Criteria
Interoperability
Full Operating
Capability
(FOC)
23

VistA Evolution Management Approach
An agile-UX-Value Management approach allows high-level, very broad
modeling and planning at the beginning of the project to address the
majority usability, UI, and project risks facing the team.
Value
Management
Feature
Driven
Design
Agile
Principles
24
• Continuous
feedback and
improvement
• Engaged
customers
and
stakeholders
• Just in time
requirements
•Plan the
program
before
starting
work
• Focuses on
system
behavior and
usability
• Requires
some system
modeling
and design
upfront

VistA Evolution Program Goals
25
The VistA Evolution Program will support this strategic plan through
continual investment and delivery of scalable and modular EHR and
Health Information Technology (IT) products to improve the quality,
safety, efficiency, and satisfaction in health care for Veterans
through:
• Interoperability
• Implementation of an open and extensible EHR system
• Establishment of interoperability between VA and DoD EHR
systems
• Re-engineering of business processes in collaboration with users
of health IT

Federal
Partners
(DOD, IHS)
VistA
VBA
Standard Data
Model
IntegratedArchitecture
andServices
By end of 2017, we will
have an architecture and
framework that supports
interoperability, care
coordination,
meaningful use and
partnership and which
has been certified to the
Office of National
Coordinator (ONC) 2017
Edition certification
criteria to support
meaningful use
demonstration by VA
providers and hospitals
Open
Source/
Community
Partners
Care
Coordination
Framework
User
Experience
26
Interoperability
Acronyms:
DoD – Department of Defense
IHS – Indian Health Service
VBA – Veterans Benefits Administration
VLERandIPOdefinethe
interoperabilitystandard

Technical (syntactic) Interoperability
• Allows computers to reliably exchange data, so it can be read at least by humans.
• Accomplished with messaging protocols and data formats.
Semantic Interoperability
• Allows computers to unambiguously and consistently determine meaning of the
data for presentation and decision support.
• Accomplished with standardized terminologies like ICD10 and SNOMed.
Process Interoperability
• Allows computers to exchange and track workflows as patients or orders move
between organizations; includes care plans.
• Accomplished with standardized business process notation or workflow protocols.
• Ex. 1: sending prescription requests from VistA to community pharmacies;
• Ex. 2: tracking care plans for follow-up on cancer suspicion from X-ray
• Ex. 3: continuing polytrauma care plans as patients move between VA and DoD.
Three Key Interoperability Concepts
27

How Do We Get to Seamless
Interoperability ?
Principles
• Mapping to National Standards is the correct approach
- VA investment will improve interoperability with DoD and other
health care partners
• “First No Harm”
- VA must balance permitted uses of shared data with our level of
confidence in coding and content accuracy
 The possibility and degree of harm
• 100% mediation is NOT to be expected
- Mediation rates in Clinical/Health Data Repository (CHDR) are ~80%
 This is still an improvement over “No Data”
28

How Do We Get to Seamless
Interoperability ?
Interagency Program Office (IPO)
• Provide and maintain complete, accurate, and meaningfully interoperable
data from all domains required to achieve clinical objectives and meet
regulatory requirements (semantic interoperability)
VistA Evolution
• Improve technical infrastructure for health data interoperability while
reducing overall system complexity (improved syntactic interoperability)
• Convert to standards-based services, formats, protocols, and data models
• Enable expanded and improved data exchange with partner providers
29

VistA Evolution Program Objectives
30
1. Provide program structure, management ,and governance to oversee
requirements management, acquisition, risk management,
communications, training, and transition planning.
2. Establish and maintain flexible system and enterprise architectures
that support interoperability with internal and external partners, and
support new applications and features that meet clinical needs.
3. Establish and maintain methods to develop business (clinical and
administrative) processes and to revise existing procedures and
policies that advance VA health care and health informatics
capabilities.

VistA Evolution Program Principles
This VistA Evolution Program Plan is based on the following
principles to ensure the highest standards of program execution:
• Focus on our Servicemembers, Veterans, and their family members.
• Enable health care that applies the appropriate and most efficient resource
to the task of providing the highest quality care while maintaining a focus
on prudent custodianship of tax payer resources.
• A cohesive, forward-looking architecture which maintains affordability
while enabling a steady and reliable evolution forward, incorporating state-
of-the-art technology while leveraging the knowledge base and processes
that create a patient-centric health care environment.
31

VistA Evolution Program Management
The importance, size, and complexity of VistA Evolution requires
adoption of robust constructs for organization and governance structure.
• The organization of scope, schedule, and cost must include the
business, technical, and program functions.
• The organizing framework must be detailed enough to practice Value
Management yet ‘light’ enough to enable agile management and
development when appropriate.
• The work breakdown structure must align to iEHR capabilities and to
business functions
• Consensus is needed on artifacts and frameworks used to execute the
program.
32

The Program Plan defines the Who and How of the VistA Evolution Program
• Management Approach
• Governance for Program Planning, Change Control, and Risk
Management
• VistA Evolution Product Approach
• EHR Certification and Meaningful Use
• Requirements Management Strategy
• Communications Strategy
• Training Strategy
• Transition Strategy
• Work Breakdown Structure
VistA Evolution Program Plan Purpose
33

The VistA Evolution Product will:
1.Deliver on the VA and DoD Secretaries’commitments to accelerate full
health data interoperability between VA and DoD
2.Tie together disparate threads of clinical data into one care coordination plan
available to the entire clinical care team
3.Deliver the greatest quality of care that supports the health status goals of
Servicemembers, Veterans, and family members
4. Will be incrementally delivered through FY17
VistA Evolution: The Product
34
The VistA Evolution product provides the infrastructure and open,
extensible platform on which tools and services can be integrated in
support of Veterans’ evolving needs, in pace with the technological
landscape. The VistA Evolution Product will be incrementally developed
and deployed through Fiscal Year (FY) 2017.

VistA Evolution Product Vision
The 4-year product vision for the VistA Evolution Product includes:
• A user experience that integrates information for improved quality of clinician and patient
reasoning;
• Sharable Clinical Decision Support (CDS) to promote best clinical practices tailored to the
patient's clinical condition and health-related goals;
• Capabilities for clinicians, managers, and researchers to define and manage patient populations;
• Management of activities that improve human and material resource utilization and clarify
plans of care for all members of the team including the patient;
• Explicit incorporation of patient goals in the care plan, to support patient-defined terms of
success, and;
• Enterprise-wide deployment.
• Achieve ONC 2014 Edition certification by September 30, 2015.
• Achieve ONC 2017 Edition certification by September 30, 2017.
35
This pathway supports the triple goals of improving the experience of care, improving the
health of populations, and reducing per capita costs of health care.

Product Management: Feature Driven
Design Process
•Identify Vision
•Identify Projects and
Teams
•Create Models
Envision
•Determine user
needs from real,
actual users
•Develop user
personas and
scenarios
•Investigate pain
points in current
system
•Investigate options
for meeting user
needs
•Investigate process
tooling
Speculate
•Organize user needs into
Features and Feature
Groups
•Develop multiple designs
for Features
•Design and test Throw Away
prototypes with real users
•Create lightweight Real
prototypes of the best
designs
•Adds/Cuts on selected
designs
•Create lightweight specs for
development
Explore
•Write code and
implement specs
•Test features for
code quality
•Test features
against scenarios
with real users
•Integrate with
other Feature
Groups and System
Adapt
•Deliver product
•Pass along key
learning's
•Celebrate
Close
• Allows for substantial upfront design and iteration and evolution in development
• This is needed to deliver features requiring highly refined design for User
Interface (UI)/User Experience (UX) controls, layout, and interaction
36

VistA Evolution
37
Beginning with delivery of new
features by September 2014, we
will analyze and begin to
synthesize existing features into
a new platform
A single viewer will become the
starting point for a new user
experience to support Patient
Aligned Care Teams, patients, and
the population
VistA Evolution
Product
VistA legacy
Connected
Health
VLER
Health
CPRS
CAPRI
VistA
Web
RDVs
HMP
Janus
JLV
VistA
Standardization
DoD iEHR
Acronyms:
HMP – Health Management
Platform
JLV – Joint Legacy Viewer
RDV – Remote Data Views

VistA Evolution Initial Operating
Capabilities (IOC): September 2014
• Capabilities enabled at two sites: Hampton Roads and San Antonio
– Advanced User Interface Tools (via Health Management Platform)
• ‘Google-like’ Search across database
• HL7 Context-aware ‘InfoButtons’ integrated into User Interface
• Medication review tool
– VA/DoD Information Sharing (via Joint Legacy Viewer)
– Immunizations
• Modernize VistA immunization files, incorporate required ‘CVX’ format
• Facilitates enabling of read/write/exchange + advanced CDS in FY15
• Enables new sources of adoption: VA Innovations, OpenCDS, IHS RPMS
– Laboratory Information System Acquisition
• Modernization and automation of ‘back-end’ lab processes
• Facilitates data exchange , business process interoperability, and enhanced CDS
– VistA Standardization
• Certification of 74 standardized VistA application routines in production (complete)
38

ONC 2014 Edition Certification of VistA
• ONC 2014 Edition Certification Criteria
– VA intends to certify 46 criteria by September 30, 2015
– The following criteria will not be certified:
• 170.314(f)(5) Cancer Case Information (optional)
• 170.314(f)(6) Transmission to Cancer Registries (optional)
• 170.314(g)(1) Automated Numerator Recording (VA will certify
170.314(g)(2) Automated Measure Calculation instead)
39

VistA Evolution Full Operating
Capability (FOC): September 30, 2017
40
Phase Two of the VistA Evolution is referred to as FOC and will be implemented from the
end of IOC (September 30th, 2014) and completed by September 30th, 2017.
The functional focus areas for FOC will:
• Propagate the usability features and end-user experience throughout all VistA Evolution to improve user
adoption, productivity, and satisfaction;
• Continue the adoption and implementation of interoperability standards for sharing clinical records
across organizations;
• Enable patient-centered care coordination as the care model woven throughout the design, and;
• Finalize the enterprise deployment of state-of-the-art laboratory and pharmacy ancillary systems, while
leveraging process re-engineering to ensure best practice operations for efficiencies, quality of care, and
patient safety.
The resulting VistA Evolution FOC application suite and underlying technical architecture
will represent a state-of-the-art enterprise EHR solution that has been certified to the
forthcoming ONC 2017 Edition certification criteria.

Keeping the Patient in Focus
41

Questions?
Contact Information:
Theresa Cullen, M.D, M.S.
Theresa.Cullen@va.gov
42

Big Data and VistA Evolution, Theresa A. Cullen, MD, MS

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