Medical Computing Status Lessons from Implementing VA’ VA’s Electronic Health Record to Improve Care “ . . . most consumers assume that healthcare is highly electronic and computerized. The reality, however, is that 90 percent of the business of healthcare remains paperpaperbased. based. Why? ” Brad Doebbeling, MD, MSc VA Health Services Research & Development Center of Excellence for Implementing EvidenceEvidence-based Practice, Regenstrief Institute, Inc, Department of Medicine, IU School of Medicine, Indianapolis, IN Except in VA ! Every VA Medical Center has Electronic Health Records and Computerized Provider Order Entry! . . . Because healthcare (in the U.S.) is a trillion-dollar cottage industry! ” Rx 2000 Institute http://www.rx2000.org/KnowledgeCenter/hipaa/elearning/QC_govt.htm What is VA – 2006? Department of Veterans Affairs (VA) Provides benefits and services to our nation’ nation’s veterans and selected family members Veterans Health Administration (VHA) Branch of VA that provides healthcare benefits Staff, Annual Budget, & Patients ~198,500 Employees • 10,000 fewer employees than 1995 > $30 Billion budget • 51% increase since 1995 Veterans Health Administration Locations, Education, & Research ~ 1,400 SitesSites-ofof-Care 154 medical centers, ~ 875 clinics, longlong-term care, domiciliaries, domiciliaries, homehome-care programs Affiliations with 107 Academic Health Systems ~90,000 trainees each year • 1,500 Health Professions Training Affiliations Nearly half US health professionals (>65% physicians) were trained in VA ~ $1.7B Research Health Services R&D, Clinical, Rehabilitation, & Basic 5.3 million patients, ~ 7.7 million enrollees • 104% increase in patients treated since 1995 – From 2.5 million patients / enrollees in 1995 Who Are VA’s Patients ? Older 49% over age 65 Sicker Compared to AgeAge-Matched Americans 3 Additional NonNon-Mental Health Diagnoses 1 Additional Mental Health Diagnosis Poorer • VA health care is a safety net for many ~ 40% with annual incomes < $16,000 ~ 31% without health insurance Changing Demographics 4.5% female overall Females: 23% of outpatients < 50 years of age 1 VA’ VA’s Health Information System is “VistA” VistA” ¾ ¾ ¾ ¾ VA runs 128 VistA systems Down from 172 VistA systems 10 years ago 180,000 PCs and thin clients “CPRS” CPRS” is the integrated EHR application Delivers a complete hospital information system - Electronic health record - Imaging - BarBar-code medication administration Hardware, software, maintenance, upgrades, staffing Success In Supporting Care Delivery For Millions Of Veterans ¾ ¾ ¾ ¾ ¾ VistA is a success Built by “fire” fire” of VHA collaboration Publicly owned by VA Strong public/private interest in using VistA National software w/ local flexibility/innovation: flexibility/innovation: Innovation developed locally & enterprise wide Standard packages distributed enterprise wide Articles About VA’ VA’s Info Technology & Quality Care “ . . . Overall, VHA patients receive better care than patients in other settings” settings” Doebbeling, Chou & Tierney. Priorities and Strategies for the Implementation of Integrated Informatics and Communications Technology to Improve Evidence-based Practice. JGIM 2006: S98-S105. Issues in IT Implementation Managing Informatics Clinician/Provider Issues Patient Issues Researcher Issues EnterpriseEnterprise-wide Issues Organizational Issues Human Factors Issues Doebbeling et al. JGIM 2006 2 Systematic Review: Impact of HIT on Quality, Efficiency, Costs of Medical Care Systematic Review: Impact of HIT on Quality, Efficiency, Costs of Medical Care Most of high-quality literature regarding multifunctional HIT systems comes from 4 benchmark research institutions HIT shown to improve quality by: - increasing adherence to guidelines, - enhancing disease surveillance, - decreasing medication errors. Much evidence on QI relates to 1° 1° and 2° 2° preventive care. --Regenstrief Institute, Harvard, Intermountain Health, VA. Little evidence available on effect of multifunctional commercially developed systems. Little evidence available on interoperability and consumer HIT. Chaudhry et al, Ann Intern Med. 2006;144:E-12-E-22. Chaudhry et al, Ann Intern Med. 2006;144:E-12-E-22. Informatics Technology For Clinical Guideline Implementation: Perceptions Of Multiple Stakeholders Types of Clinical Decision Support in VA (n=104) Facilitators of Computer Use Guideline Sharing Adherence Attitudes Custom Fit Data Data Quality Local Adaptation Available User Friendly Standard Format Documentation Essential Data Clinicians Fung & Doebbeling, Am J Manage Care 2004 Providers' Assessment Re. Extent Hospitals Provide IT for Improving Quality P e rc e n t o f H o sp itals w ith A v e ra g e R e sp o n se o f G re at o r V e ry G re a t (> 3 .5 ) 0 .98 0.9 5 0 .9 5 0 .9 0.8 0.8 6 0 .8 4 0 .79 0 .73 0.6 0.4 0 .47 0 .4 6 Overall Physician 0 .6 2 0 .59 PA/NP 0 .5 Nurse 0 .4 1 0 .2 9 0.2 0.2 2 0 .15 0 0 .04 0 .0 4 0 .0 7 0 Access to Literature/Evidence Based Medicine While Delivering Care Computer Assisted Decision Support Systems Computerized Patient Clinical Data Automation of Decisions to Reduce Errors Note IT clinical support higher in cooperative cultures Electronic Communication between Providers Electronic Communication between Providers and Patients Doebbeling et al JAMIA (in press, 2006) Evaluation Decision Support Patient Records Startup Efforts Accessible Patient Scheduling Providers Conclusions 0 .9 9 0 .98 0 .9 7 Automation Web Access Lyons, Tripp-Reimer, …& Doebbeling, JAMIA 2005 1.2 1 Education Computer Literacy Administrators VA a national leader in implementing EHR, CPOE, process improvement Quality of care in VA as good or better than private sector Implementing IT to improve quality depends on management, provider, patients, enterpriseenterprise-wide, organizational & human factors issues Need to address unique barriers and facilitators identified by stakeholders to use IT to improve quality Opportunities to enhance effective use of IT to support decision making, electronic communication, access to evidence in care delivery Needed integration of people, processes and IT in delivering evidenceevidence-based care (knowledge management) Multiple opportunities for research in implementation, program evaluation, process improvement, reengineering 3 Thank You! VA HSR&D Center of Excellence for Implementing EvidenceEvidence-based Practice 1481 W. 10th Street, Indianapolis, IN 46202 (317) 998998-4493 www.indyhsrd.research.va.gov www.indyhsrd.research.va.gov 4