Enterprise Health Management Platform VistA Evolution and Enterprise Health Management Platform Region Update by Marcia Pickard October 8, 2014

Definitions: Program and Products * Definitions: Program and Products VistA Evolution is the joint Office of Information and Technology (OIT)-Veteran Health Administration (VHA) program to refresh VistA. VistA 4 is the featured product Technical approach is to keep parts of current VistA and gradually add more modern and flexible components to allow more rapid, higher quality, less expensive addition of new functionality. VLER = Virtual Lifetime Electronic Record System VistA Evolution VistA 4 (Clinical Systems) VLER Interoperability Population Management & Analytics Top level coordinates among product lines Program Product Lines This product line is pre-decisional Patient-centric, Team-based, Quality-driven

2014 2015 2016 2017 2018 VistA 4 Product Roadmap Colleague EHR Gen 4: Advanced systems that provide substantial functionality for nurses, physicians and pharmacists; have more decision support and workflow capabilities along with tools that permit providers to more easily bring Evidence Based Medicine to the point of care. Colleague EHR (Gartner Gen 4) Care Coordination Interoperability and Improved Care Management Core Care Management and Office of National Coordinator (ONC) Certification Initial Care Management Capabilities

Before VistA Evolution – The Health Informatics Initiative (hi2) “Transform Healthcare Delivery through Health Informatics” (Health Informatics Initiative or hi2) was created by Secretary Shinseki in May 2010 with these missions: Provide foundational Information Technology (IT) and Informatics components for Veterans Health Administration (VHA)’s transition from a medical model to a patient-centered model of care. Build a sustainable collaborative approach, capacity, and tools to deliver informatics solutions to transform health care delivery to Veterans through three major projects or Workstreams. Build a platform and functionality to support collaboration with VistA Evolution and Computerized Patient Record System (CPRS) – Health Management Platform (HMP) Transforming Health Care Delivery through Health Informatics (hi2) is a VA Major Initiative launched in September, 2010. hi2 will shape the future of VHA health information systems through deliberate application of IT and health informatics to deliver solutions, improves quality and accessibility while optimizing value. The newly formed VHA Office of Informatics and Analytics (OIA) ultimately will incorporate both the clinical and business functions of hi2. The Initiative supports establishment of cross-cutting health informatics tools designed by health professionals to optimize performance in terms of quality, efficiency and increased job satisfaction. It encourages and facilitates increased patient and family engagement in care and decision-making; and support population and evidence-based care focused on preventive and chronic disease management.  In FY12, the Initiative will continue to develop the infrastructure / framework to support a predominantly web-based Electronic Health Management Platform plus a Software Development Kit - enabling contributions from other software development sources.  Additionally, it will establish a sustainable workforce capacity to support healthcare modernization and improved care delivery. The workforce capacities component will build on agency successes with continued development of informatics career paths and standard position descriptions. It will also deliver additional informatics coursework and improve coordination and communication strategies amongst VA Health Informaticists.

Health Management Platform (HMP) Hi2 committed to providing HMP capabilities to two sites by Sept. 2014 (IOC carryover from iEHR milestone) Commitment was met by production implementation of HMP at San Diego, Hampton and San Antonio, including these capabilities: Google-like Search across patient records Improved Medication Review InfoButton links to external medical references News Feed Tasks CPRS classic views HMP currently complements but does not replace any part of CPRS.

Enterprise Health Management Platform (eHMP) Large contract award to ASMR/Agilex in September 2013 – referred to as UX (User Experience) HMP code has been provided to ASMR/Agilex to serve as the foundation for the enterprise product (eHMP). VPR is being reused, but the UI is a new start. Hi2 team has transitioned from initiative status, merging with Dr. Nichol’s office – Health Solutions Management – effective October 1, 2014, and will continue to contribute code to eHMP

eHMP and eVPR The combination of the HMP, JLV and User Experience teams’ efforts will become Enterprise Health Management Platform (eHMP) Will become the eventual CPRS replacement eHMP will be a Product that consists of multiple components: eHMP GUI, Enterprise Virtual Patient Record (eVPR), and Vista Exchange VistA will continue to be an authoritative data store where it is so today

Enterprise Health Management Platform (eHMP) eHMP User Experience Vista Exchange Clinical Decision Support Context Persistence Orders Selection Service Orders Management Service Data Annotation Service Clinical Workflow Concept Relationship Service Documentation and Text Search Service Business Rules Management System eHMP Services Middle tier Components JLV View CPRS Features HMP IOC Features ONC Certification Features

eHMP – User Experience eHMP will provide end user clinical encounter and care coordination transaction capabilities, data visualization, and decision support integration between Provider, Patient, and System facing components and devices. Different capability configurations will be available based on user roles. eHMP will: become the eventual CPRS replacement maintain the joint VA/DoD JLV functionality provide new clinical functionality be used for ONC 2014 edition certification

VistA Exchange and eVPR VistA Exchange is the VistA 4 clinical application data services engine, providing an enterprise Virtual Patient Record service (eVPR) optimized for the enterprise Health Management Platform (eHMP) and other point of care applications and workflows eVPR includes information model binding, terminology normalization, knowledge enrichment, and search indexing for all available longitudinal patient record data aggregated from VA, DoD, and exchange partner sources.

Abstracted Architectural Roadmap 2014 2015 2016 2017 2018 Cut IT funding Pop Health Scalable architecture Advanced decision support Better user experience Add data abstraction layer External applications Native standardized data eHMP Replace some VistA applications Enhance VistA database and some VistA applications Critical fixes VistA Base Enhance interoperability (get data from external providers) Standardize clinical terms VLER Patient-centric, Team-based, Quality-driven

eHMP FY 14-16 PSI Functional Roadmap (Proposed) PSI-6 Nov 18 – Feb 23 ‘15 Tasks CPOE Drug-Drug/Drug-Allergy Interaction Drug-formulary Checks eSignatures Documentation Immunizations Smoking Status Info Presentation Persist user references User-defined views/filers CPRS Graphing Patient Inquiry/Insurance/MHV T.O.C. Receive, Display, and Incorporate TOC Create/Transmit TOC CDS Open CDS PSI-7 Feb 24 – May 18 ‘15 Tasks ePrescribing Documentation Clinical reconciliation - Med reconciliation Info Presentation VistA Web Health Summaries/Report VistA Imaging CPRS Graphing Reports CPRS T.O.C. Clinical Summary (AVS) CDS ONC CDS PSI-8 May 19 – Aug 24 ‘15 Tasks Orders/Tasks Documentation Amendments Note objects Free text notes & old note objects Info Presentation Image Viewer Printing CPRS Graphing Reports CPRS T.O.C. Data Portability Clinical Summary (AVS) CDS Patient Specific Education Open CDS other Authoring Concept Relationship Other CDS Workflow Management Care Plan Basic

eHMP FY 14-16 PSI Functional Roadmap (Proposed) PSI-9 Aug 25 – Nov 17 ‘15 Tasks Order sets Quick orders Order Menu Formulary Restricted ePrescribing Documentation Progress Notes Modernization Documentation Kit [Legacy/New] Family History Smoking status Functional Status Annotation* Encounters Templates, fields, objects Info Presentation VBA User Printing Reports CPRS Concept-driven displays PSI-9 Continued CDS Clinical Reminders Replacement – KBS help? Other CDS Concept relationship authoring Workflow (CDS support) Care Plan PSI-10 Nov 17 – Feb 22 ‘16 Tasks Order authoring Order sets In patient meds for Outpatient Documentation Progress Notes Modernization Dialogs [Legacy/New Info Presentation Printing CDS Clinical Reminder Translation - Contract? Other CDS Workflow (CDS support) Care Plan

eHMP FY 14-16 PSI Functional Roadmap (Proposed) PSI-6 Nov 18 – Feb 23 ‘15 VPR Sync Sync Overhaul Cache update on write-back Support CDS to update RPCs User Identity & Access Services ABAC User Repository User Provisioning ONC Audit Performance VistA Routine Dep Split Resource Server (clusters) Monitoring System Monitoring External Integration jMeadows NwHIN DoD Adapter VPR APIs VX Patient record VSA Spike PSI-7 Feb 24 – May 18 ‘15 User Identity & Access Services SSO/PIV Authentication Performance SOLR PEP Authentication Validation in parallel Monitoring Production Level Monitoring (similar to JLV) External Integration jMeadows VSA DR/Failover 2 sites PSI-8 May 19 – Aug 24 ‘15 Performance Concept Searches Reverse Proxy Change External Integration VSA PSI-9 Aug 25 – Nov 17 ‘15 DR/Failover Multi site

Modularity and SDK in eHMP Development modularity and services will exist at multiple levels – user interface, middle tier, data levels Software Development Kit (SDK) will be made available to the community. The SDK is comprised of: Application Development Kit (ADK) to drive development of the client-side web application. Build using JavaScript, backbone.js, marionette, bootstrap. Resulting application is SPA, static HTML served from web server (no J2EE server) Resource Development Kit (RDK) to drive the development of service side resources (web services) to support the web application. Build using JavaScript, express.js. Deploy to node.js; relies on npm for package management.

eHMP Application Development Kit (ADK) ADK provides mechanisms for applet developers to Discover the current patient Fetch patient data from vista exchange, can use canonical model (based on VPR) or provide custom "view" model Bind data to backbone views, provide templating Choose preselected display paradigms (tableview, etc) and UI controls. UI style set by application Create three different "size" views to support responsive / adaptive design ADK provides mechanisms for screen designers to Create a screen, choose from predefined layouts and assign applets to regions ADK provides for application designers Runtime UI shell for application. Displays current patient, current user. Provides navigation Mechanism to choose the screens that are part of the application ADK also provides CI pipeline/devops for pulling applets/screen configurations from artifact repository, compiling, packing, testing, and publishing to artifact repository. This produces a CM-ed version of the web application (which includes specific version of applets)

eHMP Resource Development Kit (RDK) Resource = a single web service (e.g., save allergies) Resource Family = collection of resources Resource Server = deployable unit, including a family and configuration RDK for resource developers Configuration of the resource family For each resource, specifies relative mount path and method using standard express signature function(request, response, next) Specifies resource characteristics (sensitive, audit information) Request provides resource information about the request: url, path parameters, query parameters, header, current user, access to RDK utility methods, access to current resource server, configuration information, logger Response provides resource ability to send response: status code, json or text body, media information Resources with handles to common external systems, including JDS, VistA(s), solr search engine

eHMP Resource Development Kit (RDK) RDK for deployment engineers when creating a resource server Group resources into a logical deployment unit called a resource server. Specify how many processes using cluster/fork Deployment engineer chooses which resource family should be registered using: (show code) Resource Server deployed behind a reverse proxy (apache httpd) for load balancing Ability to enable: authentication, authorization/PEP, audit Specify logging rules, configuration, resource caching rules Routes calls to resources based on URL and media type (content-negotiation) Provides health check (binary and discrete information) based on each resource registered. Deployment engineer can specify additional health check rules. RDK also provides Centralized dependency management Automatic creation of resource directory CI pipeline/devops for pulling applets/screen configurations from artifact repository, compiling, packing, testing, and publishing to artifact repository. This produces a CM-ed version of the web application (which includes specific version of applets)

Logical View of Patient Encounter – VistA 4 (Simplified) ‘Local’ VistA RPC CALLS (WRITE) eHMP integrates HMP/Mobile/JLV Team – Patient - System RPC Broker READS – (VDEF, RPC and FMQL) VistA Shadow Remote VistA Terminology Service CDS Support Services VistA Exchange SFC(Ret) Smith’s Care Team READS Future Services (ie., Orders) Future Services (Knowledge Base) Remote VistA READS Access Management Identity Management MHV CDW VINCI VLER DAS Consent Management FHIR VA DoD Partners VA Partner DMIX / DHMSM HIE VA Partner MDR BHIE SHARE AHLTA DHMSM VA Partner CHCS DoD VLER ADAPTER HSDW DoD Partner Essentris DoD Partner CDR PDTS DoD Partner ESB connections (with VSA services) DRAFT