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Slide 1: Introduction to Free / Open Source VistA EHR OSCon, 2010 K.S. Bhaskar, FIS David Whiles, Midland Memorial Hospital Ben Mehling, Medsphere Systems
Slide 2: Agenda What is VistA? Clinical Transformaion FOSS Technology Stack VistA FOSS Landscape Getting Involved Questions
Slide 3: What is VistA?
Slide 4: What is VistA Origins within the Department of Veterans Affairs Adoption by US Federal Government Department of Defense (CHCS) Indian Health Service (RPMS) Availability under FOIA
Slide 5: Outside US Federal Government Domestic Secondary Care - e.g., Midland Memorial Hospital Primary Care - e.g., Clinica Adelante Other - e.g., Oklahoma State Veterans Homes International Egypt Mexico Jordan India
Slide 6: Clinical Transformation
Slide 7: Midland Memorial Hospital Hospital Background Midland, Texas Population – 101,000 320 licensed beds, 2 sites Annual Inpatient Admissions – 11,000+/Annual ER Visits – 50,000+ Key Project Milestone Dates Jun '03 - WorldVistA Conference Dec '04 - Professional Services - Medsphere Q4 '05 ~ Q1 '07 - Phased Go-lives Jan '08 - Recognized as a HIMSS Stage6
Slide 8: Awards and Recognitions Jan 2008 Recognized by HIMSS Analytics as Stage 6 Hospital August 2008 Recognized as a “Top 25 Connected Healthcare Facility” by Health Image and IT November, 2008 Recognized as one of 100 finalists by Info World 2009 CIO 100 Award Winner 2009 American Business Awards (Stevie’s) Finalist in Information Team of the Year Category
Slide 9: Project Budget VistA software license Consulting (primarily Medsphere) Hardware Wireless infrastructure Interfaces, etc. Remodeling Total $ 0 5,126,000 801,000 226,000 140,000 100,000 $ 6,393,000
Slide 10: It's about the healthcare, stupid Requirements Product Maturity Proven Functionality Adoption Innovation Commercial support & maintenance Affordability Addressing Organizational Concerns & Perceptions Engagement of end-user (all providers, clinical staff, etc.) Educate, educate, educate... Internal marketing and sales Perceived risks of open source (in healthcare)
Slide 11: It's actually about the Patient Immediate care giver access to record Improved clinical processes Order entry Medication administration Documentation Results Mortality Rates ~2 lives/month Improved clinical outcomes Reduced Central Infection Rates Reduced Medication Errors Reduced Morbidity & Mortality Improved Patient satisfaction Central Line Infection Rate 88% decrease
Slide 12: FOSS Technology Stack
Slide 13: VistA: An application suite VistA is not an application The Monograph catalogs VistA's 100's of applications Application Categories: Health Data Registration, Enrollment & Eligibility Health Provider Management & Financial Common Services http://www.va.gov/vista_monograph/
Slide 14: Stack & Core Applications
Slide 15: M Engine & FileMan DBMS Database & Application Server NoSQL - data in B*-trees: Compact Sparse data Fast Executes M code: ISO standard 3GL / Procedural Database access is just an array reference Database Management System Defines data structures, relationships, indices, triggers, etc. Benefits from underlying B*tree structure, compactness, speed
Slide 16: Extending the Platform - OVID Can be used for Integration, Extension and Migration projects Java-based domain layer, access VistA data and logic from Java, SOAP or REST -- or access external data from within VistA. Being used to build integration modules, CCD/CCR interop, thick clients, web apps, mobile apps, etc. Project Home - https://medsphere.org/community/project/ovid Presentation & Demo: http://medsphere.blip.tv/file/3736408 OVID Whitepaper - http://medsphere.com/ovid-white-paper
Slide 17: Extending the Platform - FMQL Wrap VistA in a SPARQL endpoint and the most popular EMR in America becomes a patientknowledgeable member of the Semantic Web FileMan Query Language (FMQL) is a subset or profile of SPARQL suitable for this repository Project Home - http://www.caregraf.org/semanticvista Presentation - http://www.caregraf.org/worldvistapres/wvpres.html#slide1 "Vegan Vet" Demo - http://www.caregraf.org/veganvet/demo
Slide 18: Extending the Platform - EWD Advanced web application development technology and Ajax tagging library. Extend M-based applications onto the web in a modern, AJAX framework Technology used to rapidly develop web apps using an M back-end Project Home - http://www.mgateway.com/ewd.html Build an iPhone app - http://www.youtube.com/watch?v=M04zyMPMnKU Case study - http://tinyurl.com/6qrrx8
Slide 19: Extending the Platform - FM Projection Projects VistA data structures into a relational database format using a MySQL data storage engine -- data is "projected" not "replicated" Users, applications, and dashboards can query against FM data structures using SQL and related tools Project Home - https://medsphere.org/community/project/fm-projection Presentation & Demo: http://medsphere.blip.tv/file/3736408 (skip to 2nd half)
Slide 20: VistA FOSS landscape
Slide 21: VistA FOSS landscape - events VistA Community Meetings WorldVistA Education Seminars VeHU
Slide 22: VistA FOSS landscape - distributions FOIA VistA & FOIA RPMS WorldVistA EHR Medsphere OpenVista DSS vxVistA
Slide 23: VistA FOSS landscape - projects Interfaces Practice Management System / Billing Lab e-Prescribing Continuity of Care Record / Document (CCR/CCD) Clinical user interfaces - TMG CPRS Clinical - pediatric growth charts Technical "Megapatch" KIDS builds Porting RPMS to GT.M; merging RPMS & VistA Meta-packaging - Astronaut
Slide 24: VistA FOSS landscape - organizations Non-profit WorldVistA - http://worldvista.org/ VistA Expertise Network - http://vistaexpertise.net/ Commercial Medsphere - http://medsphere.com DSS - http://dssinc.com Dell Perot - http://dell.com OHUM - http://ohum.org Astronaut LLC - http://astronautvista.com FIS (GT.M) - http://fis-gtm.com Many consultants...
Slide 25: VistA FOSS landscape - lists Hardhats - technical http://groups.google.com/group/hardhats WorldVistA services - business related http://groups.yahoo.com/group/worldvista-services VistA - all else, including advocacy http://groups.google.com/group/vista
Slide 26: VistA FOSS landscape - communities Hardhats - http://hardhats.org WorldVistA - http://worldvista.org Medsphere - http://medsphere.org VxVistA - http://vxvista.org
Slide 27: Getting Involved Collaboration is welcome at any level of the "collaborative stack" -- clinicians, informaticists, developers, and more. Join a mailing list Find a project Engage the community Communities http://Hardhats.org http://WorldVistA.org http://vxVistA.org http://Medsphere.org Links & Resources VistA @ Wikipedia VistA Community Projects & Discussion Lists Documentation, Training, & Educational Resources VistA Resources VistA-based Distributions
Slide 28: Questions K.S. Bhaskar FIS http://fis-gtm.com/ David Whiles Midland Memorial http://midland-memorial.com/ Ben Mehling Medsphere Systems http://medsphere.org
Slide 29: Addendum
Slide 30: Clinical Transformation
Slide 31: MMH - Anecdotal Improvements Safety and Quality Non-compliance with documentation of date and time has been essentially eliminated. EDITH has eliminated the time spent clarifying orders and documentation due to handwritten legibility issues. Immediate access and availability has made it easier to conduct chart audits in support of regulatory and accreditation requirements. Bar-coded Medication Administration has helped reduce the rates of self-reported medication errors.
Slide 32: MMH - Anecdotal Improvements Safety and Quality cont. Unapproved abbreviations have reduced significantly. During the recent Joint Commission survey, surveyors found two unapproved abbreviations and they were both handwritten on paper documents. Pharmacists are now more clinically focused; they are no longer just a dispensing pharmacy. Lost charts have been eliminated. Helps radiology staff identify isolation patients and “Do Not Resuscitate” status.
Slide 33: MMH - Anecdotal Improvements Safety and Quality cont. There are fewer ordering errors made with direct entry. Use of topic-focused notes, e.g. documentation requirements for pressure ulcers, has helped improve capture of all documentation components since they are all together in one place in the record. Quality Management is now doing concurrent monitoring for compliance with core measures. Quality management reports that they “Would not have been able to do the nursing quality dashboard without EDITH.” The pressure ulcer rate was just over 20 percent and has dropped down to 3-5 percent.
Slide 34: MMH - Anecdotal Improvements Safety and Quality cont. Quality Director reports, “With concurrent review it’s allowed us to set the stage for cultural change; quality is real time and it never used to be.” In the Emergency Department, requests for the paper chart would take anywhere from 20 minutes to the next day (if in the middle of the night and the House Supervisor was too busy). Now access is immediate. Timely administration of antibiotics on admission for patients with pneumonia has improved.
Slide 35: MMH - Anecdotal Improvements Operational Efficiency Remote access has helped physicians decrease time spent doing rounds as they are able to come prepared with lab and procedure results ahead of time. Time spent reviewing records is now quicker, resulting in faster resolution of patient complaints. Delays in retrieving paper medical records have decreased. Pre-implementation it would take on average one week to retrieve the paper record for review. Record is now immediately accessible.
Slide 36: MMH - Anecdotal Improvements Operational Efficiency cont. Chart availability helps everyone to fulfill their role and allows for simultaneous access to the same record by different roles. Medication verification can now be conducted more timely due to the ability to better allocate pharmacist coverage for this function. Information availability on outpatients and Emergency Department patients has helped radiology staff pre-plan interventions and improve continuity of care. Ability to cut and paste text saves time entering documentation.
Slide 37: MMH - Anecdotal Improvements Operational Efficiency cont. Availability of electronic signature has helped reduce time spent authenticating records. One physician used to have to go to Medical Records to sign charts once per week or every three weeks. Now this can be done remotely. Now can do 50 charts in 20-30 minutes. Physician medical record deficiencies have reduced from 37-41% previously to 25% now. Charge nurses are rounding with computers on wheels to improve communication.
Slide 38: MMH - Anecdotal Improvements Return on Investment Lab has eliminated the practice of printing lab reports and placing on the chart resulting in an approximate 99% reduction in lab paper costs. Lab has decreased the use of labels combining more tests to an accession number to print on one label; now using generic labels used by the Veterans Administration hospitals in lieu of more costly custom labels. Lab has decreased the count of terminals used in the department. They have removed 6-8 terminals due to work flow changes since technologists do not need as much interaction with the system.
Slide 39: MMH - Anecdotal Improvements Return on Investment cont. EDITH has helped reduce record storage costs by reducing the needs for physical space for storage of medical records. The availability of McKesson Interqual and Milliman and Roberts criteria embedded in EDITH has helped with concurrent review. EDITH has greatly improved the time it takes to get charts coded due to improved access and availability. EDITH helped the organization catch up on a backlog of $16.7 million of coding records and billing in 4 weeks (about 4500 records).
Slide 40: MMH - Anecdotal Improvements Evidence-based Decision Making Use of physician order sets has reduced variability Physician specific discharge instructions in day surgery are being turned into order sets.