Medical Computing Status Lessons from Implementing VA ’ s

advertisement
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”
ƒ
¾
¾
ƒ
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
ƒ
¾
¾
¾
ƒ
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
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
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
ƒ
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
ƒ
HIT shown to improve quality by:
- increasing adherence to guidelines,
- enhancing disease surveillance,
- decreasing medication errors.
ƒ
Much evidence on QI relates to 1°
1° and 2°
2°
preventive care.
--Regenstrief Institute, Harvard, Intermountain Health, VA.
ƒ
Little evidence available on effect of
multifunctional commercially developed systems.
ƒ
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
ƒ
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
ƒ
PA/NP
0 .5
Nurse
0 .4 1
ƒ
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
ƒ
ƒ
0 .9 9 0 .98
0 .9 7
Automation
Web Access
Lyons, Tripp-Reimer, …& Doebbeling, JAMIA 2005
1.2
1
Education
Computer Literacy
Administrators
ƒ
ƒ
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
Download