Enabling Health Care Efficiencies via an Interoperable Health Record Paul Tibbits Deputy CIO for Enterprise Development Department of Veterans Affairs November 12, 2009

Interoperability: Current and Planned

3 Current State KEY Current Sharing (Viewable) Planned Sharing (funded) Potential Sharing (unfunded & uncosted) Current Sharing (Computable) Potential Sharing (VA funded; DoD identified funding requirements – FY09 supplemental) On Contract Potential Sharing (DoD funded) BEC IS/IT WORK GROUP HEC IM/IT WORK GROUP Accessions & Separations Combat Military Pay Activation / Mobilization MGIB Eligibility Information Add’l Education Benefit Data UIC Mailing Address Data Military Pay Information Insurance/ Benefit Eligibility MGIB Program Usage Data Military Service Imaged Record via DPRIS Compensation & Pension Data Member / Veteran Family Member Information for Insurance and Cemetery Benefits Defense Center of Excellence (DCOE) Research Clearing / Data- mart (LOA2) TBI Patient Registry (LOA2) TBI / PTSD Telehealth Consult (LOA2) Phase 1 of Common Services Initiative Phase 2 of Common Services Initiative Non-Clinical Case Mgmt. (LOA3) Web-Based FIRP (LOA3) VA Disability Exam Templates (LOA1) Imaging - Theater (LOA4) Reserve Health Records Access (LOA4) Cognitive Assessment Tool (LOA2) Clinical Enhancements Web-Based Training (LOA2) TBI Extender Codes (LOA2) Behavioral Health Notes (LOA2) Plan Completed Jun 08 Images (Enterprise-Wide) DoD and VA Shared Health Data Post-Deploy Reassessment Std Ambulatory Data Record Problem Lists Additional Inpatient Data Discharge Summaries Post-Deploy Assessment Procedures Vital Signs Allergy Data Radiology Reports Operative Reports Other History Pharmacy Data Inpatient Consults Theater Clinical Data Social History Pre-Deploy Assessment Lab Results Provider Notes Family History Questionnaires Interoperability Plan, V 1.0 Completed Sep 08 Add’l Data Elements (Viewable) Add’l Data Elements (Computable) Sep 09 Oct 09 Document Scanning (initial) Inpatient Documentation Expansion Gateways - Data Migration Expansion of Questionnaires Lab Results (computable) Plan Completed Jun 08 Interoperability Plan, V 1.0 Completed Sep 08 Images (Enterprise-Wide) Add’l Data Elements (Viewable) Add’l Data Elements (Computable) DoD and VA Shared Personnel / Administrative Data eBenefits Portal (LOA4) Dis Eval Sys Pilot - VTA Tracking (LOA1) Wounded Warrior Indicators (LOA4) Clinical Case Mgmt. (LOA3) ADT to DFAS (LOA8) Document Mgmt. System (LOA1)

4 North Chicago – Captain James A. Lovell Federal Health Care Center First FHCC managed jointly by VA and DoD Opening Day October 2010 On Schedule Provide Information Management/Information Technology Key to establishing VA/DoD electronic health record Ambulatory Care Center site

Other Government Agencies Beneficiary / Stakeholder Managed Care / Fee Private Providers 5 DoDVA Common Services DoD Unique Data Ex: Enrollment, Operational/Theater Information VA Unique Data Ex: Extended Care Data, Veteran/Dependent Benefits Proposed Future State AccessionTrainingReadiness Deployment Education Personnel Data Compensation Medical Care: Theater & Home Separation VA Extended Care Memorials Survivor Benefits Army Navy Marine Corps Air Force JOINT Health | Benefits | Personnel Virtual Lifetime Electronic Record VHA NCA VBA Identity Management Self-Service Logon Compensation Benefits & Eligibility Education Portable Order Entry Single Sign-On Pharmacy* Consults Lab* Radiology* Service History Other Uniformed Services * Orders and results

Nationwide Health Information Network Health Bank or PHR Support Organization Community #1 Integrated Delivery System Community Health Centers Community #2 CDCVA CMS DoD SSA State and Local Gov Labs Pharmacies The Internet Standards, Specifications and Agreements for Secure Connections Mobilizing Health Information Nationwide

Architecture and Technical Challenges

Top 10… SOA General Misconceptions 10. Orchestration = dynamic discovery = dynamic consumption 9. Configurable = loosely coupled 8. Identity is Identity, and there is only 1 7. SOA is a “Big Bang Theory” 6. Granularity of services is easy to define 5. Standards and Specifications compliance is strictly defined 4. WSDL exchange = interoperability 3. Security and auditing can be retrofitted 2.Service-Oriented Architectures are primarily a technical or management approach And the #1 General misconception is… 1. SOA is the answer to interoperability (and you can buy one)

Approaching Service Orientation Strategic Governance needs to enforce the “design by standards” approach versus “design by product” across the Enterprise Critical elements required to scale Tactical Governance Model –Enterprise review boards –Programmatic Governance Boards: Enterprise Management Processes –Functional Governance Boards: portfolio and capability establishment –Technical Governance Boards Roadmap for core services utilized by all development efforts Reference Architecture to enable experimentation and development including Standards, Specifications, Patterns and Practices (SSPPs) VA Internal Use Only 9 FEA Infrastructur e Components Information & Data Application s Services Business Components (Functions, Sub-functions, and Capabilities Strategic Goals & Objective s Eight for Excellence VHA Domains of Value Medical Researc h Medical Researc h Medical Care Medical Care Medical Educatio n Medical Educatio n Care Mgmt Employee Health Record Employee Health Record Sub- Function 1 Sub- Function 2 Sub- Function 3 Sub- Function 4 Information Element 1 Information Element 1 Service 1 Services 2 Service n … Service 1 Service 3 VBA Service 4 NCA Service 6 Composite Apps Messagin g DiscoverySecurity Core Services BRM DRM SRM TRM PRM ESM Information Element 3 Information Element 3 Information Element 4 Information Element 4 Information Element 2 Information Element 2 Information Element 5 Information Element 5 Information Element 6 Information Element 6 VBA NCA VBA Strateg y VBA Strateg y NCA Strateg y NCA Strateg y VBA Lines of Business VBA Lines of Business NCA Lines of Business NCA Lines of Business VBA Business Area VBA Business Area NCA Business Area NCA Business Area VBA Sub-Functions NCA Sub-Functions VBA Information Element VBA Information Element NCA Information Element NCA Information Element VBA Service 6 NCA Service 6 VHA Service VBA Service VBA Service NCA Service VBA Service NCA Service E-SOA Governance VA Pillars Governanc e Requirement Framework Requirement Framework Organizational Governance Organizational Governance Open Community Process Open Community Process Business Process Modeling Business Process Modeling Data Strategy Data Strategy Metrics Test & Assessment Certification & Accreditation Certification & Accreditation Deployment Strategy Deployment Strategy Education & Training Education & Training Technical Standards

Example: Chapter 33 Tactical Governance Implementing Governance for Chapter 33 –Established OED / Chapter 33 Architecture and Engineering Governance Board –Established ESOA / Chapter 33 Architecture Integrated Product Team (IPTs) to manage issues in key areas Security, Architecture, Infrastructure VA Internal Use Only 10 ESOA / Ch 33 Arch IPT Charter OED / Ch 33 Arch-Eng Governance Board Charter SPAWAR (Chair) Ch 33 Technical Team VBA-SE EIE OED-SE OED-SE (Chair) VBA Architect PM Rep EIE Rep BOIBI Rep Field Ops Security Identifying and managing critical gaps in Governance for Chapter 33 –Process and artifacts that: Identify connection to systems outside CH33 Determine responsibility for changes to these systems Determine service agreement type Enable CH33 service deployment and certification Developing service-oriented Standards, Specifications, Patterns and Practices (SSPP) and an associated reference implementation of core services Chapter 33 Tactical Governance Chapter 33 Governance Model is scalable to the Enterprise level

Innovation

Innovation Components  Greenfield Incubation—field innovators propose new opportunities  Strategic Incubation*—leadership identifies opportunities  Innovation Diffusion—evaluation of the quality of products and how products work in the healthcare delivery process  Collaborative Tools—technologies used to advance innovation and encourage the building of communities of interest  Workforce Development—activities undertaken to build a culture of innovation and a knowledgeable workforce  VA OI&T Innovation Advancement Program (IAP) *cross-Administration strategic initiatives to be undertaken; points of contacts have been identified 12

Innovation Evaluation Innovation criteria –Improves patient care (e.g., safety, quality or access) –Improves efficiency (e.g., clinical workflow or cost/benefit) –Impacts numerous Veterans, staff or other stake holders –Addresses an unmet need rather than incrementally improves existing methods –Helps meet an organizational requirement (e.g., Joint Commission or Congressional mandate) Three review teams, five reviewers per team with multi-discipline and leadership level mix Preliminary Review Process: –Addressed Conflicts of Interest –Randomly assigned LOI to teams –Used blinded independent review with established Innovation Evaluation Criteria on 1-5 scale –Group discussed and determined final scoring Final Review Process and Criteria: –Same review teams, evaluated full proposals –Benefit factors: Quality, Efficiency, Scope, Novelty, Requirement –Feasibility factors: Team, Approach, Environment

Greenfield Award Overview Category Reviewed LOI Impacting Category Awards Impacting Category Award Percent Administrative % Clinical % Education562138% Other34926% Veteran Direct Impact % 44 TOTAL CONCEPTS SELECTED FOR FUNDING

Program Management and Acquisitions

16 Analysis of Ongoing VA Programs 280+ programs reviewed 8 program attributes analyzed Many programs exhibited signs of trouble –Greater than 13 months behind schedule –Greater than 50% over initial cost estimate –Decrease in software quality between releases –Inadequate skills to complete program Substantial change required

17 Incremental Development All new VA IT projects/programs must use an incremental development approach –Frequent customer delivery milestones at maximum of six months –Customer must test and accept functionality To be approved for investment, a program or project must have: –An identified customer sponsor and integrated project team (IPT) –Program plan that documents frequent delivery milestones –Documented, agreed to requirements for initial milestones –Clear plan for necessary program disciplines –Clear access to necessary program resources –Customer, program, and vendor acceptance of PMAS –Jointly established success criteria

18 Program Management Accountability System (PMAS) All incremental development programs will be managed rigorously to schedule –A program/project will be halted on its third missed customer delivery milestone Once halted, substantial changes must be made before the program can restart –Need for program/project will be re-assessed –Program approach will be re-assessed –Make/buy and program design decisions will be re-assessed –Program management assignment will be revisited –Government staff assignments will be revisited –All service contracts will be re-visited –New program plan must be approved Flexibility can be earned Collaboration is key to IT success.

Acquisitions Established a dedicated acquisition office to support OIT program planning and execution Provide life cycle acquisition support from program inception through completion by a multi- functional IPT Implementing joint Program Management Reviews to improve contract performance and program execution Collaboration with industry through early involvement of requirements and transparency Acquisitions plays a dedicated and integral role in project IPTs.

Conclusions Investment vs. Value Consensus of IT “Sellers” and “Buyers” on Business Need Need for Incentives Information Interoperability Collaboration at all Levels Essential Rigorous Program Management and Acquisitions Process